- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.75 / $351.06 / $1,523.02
| Professional | | $146.75 | $351.06 | $1,523.02 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $73.38 / $175.53 / $761.51
| Professional | 52 | $73.38 | $175.53 | $761.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.20 / $521.67 / $2,001.85
| Professional | | $309.20 | $521.67 | $2,001.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.39 / $619.76 / $2,903.44
| Professional | | $186.39 | $619.76 | $2,903.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,596.00 / $7,457.00 / $12,945.00
| Facility | | $4,596.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.43 / $1,859.47 / $2,891.12
| Professional | | $1,336.43 | $1,859.47 | $2,891.12 |