- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $3,467.37 / $3,548.13
| Facility | | $724.44 | $3,467.37 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $354.81 / $1,000.00
| Professional | | $169.82 | $354.81 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $478.63 / $1,202.26
| Professional | | $177.83 | $478.63 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $616.60
| Facility | | $295.12 | $295.12 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $239.88 / $239.88 / $239.88
| Facility | 52 | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $426.58 / $1,318.26
| Professional | | $199.53 | $426.58 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $630.96 / $1,737.80
| Professional | | $194.98 | $630.96 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $3,467.37 / $3,548.13
| Facility | | $776.25 | $3,467.37 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $478.63 / $1,348.96
| Professional | | $177.83 | $478.63 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $446.68 / $1,258.93
| Professional | | $190.55 | $446.68 | $1,258.93 |