- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $633.50 / $2,502.00 / $6,060.00
| Facility | | $633.50 | $2,502.00 | $6,060.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.91 / $310.52 / $1,747.05
| Professional | | $149.91 | $310.52 | $1,747.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.24 / $164.91 / $297.45
| Professional | | $125.24 | $164.91 | $297.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $552.79 / $1,971.42 / $3,610.48
| Facility | | $552.79 | $1,971.42 | $3,610.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.98 / $272.22 / $1,386.16
| Professional | | $197.98 | $272.22 | $1,386.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.00 / $971.62 / $1,591.99
| Facility | | $446.00 | $971.62 | $1,591.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.77 / $286.07 / $1,901.37
| Professional | | $155.77 | $286.07 | $1,901.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.00 / $351.15 / $1,904.40
| Facility | | $154.00 | $351.15 | $1,904.40 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $551.04 / $551.04 / $3,716.72
| Facility | 52 | $551.04 | $551.04 | $3,716.72 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $137.76 / $137.76 / $929.18
| Facility | 53 | $137.76 | $137.76 | $929.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.44 / $1,120.58 / $7,882.64
| Professional | | $163.44 | $1,120.58 | $7,882.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $966.00 / $2,517.00 / $4,486.00
| Facility | | $966.00 | $2,517.00 | $4,486.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.78 / $1,024.65 / $2,090.98
| Professional | | $158.78 | $1,024.65 | $2,090.98 |