- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $3,715.35 / $9,332.54
| Facility | | $645.65 | $3,715.35 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $645.65 / $1,412.54
| Professional | | $218.78 | $645.65 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,128.61 / $10,964.78
| Facility | | $1,698.24 | $5,128.61 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $616.60 / $1,412.54
| Professional | | $223.87 | $616.60 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $1,148.15 / $3,890.45
| Facility | | $354.81 | $1,148.15 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $302.00 / $302.00 / $302.00
| Facility | 52 | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $616.60 / $1,513.56
| Professional | | $251.19 | $616.60 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $2,630.27 / $6,309.57
| Facility | | $660.69 | $2,630.27 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $575.44 / $1,230.27
| Professional | | $213.80 | $575.44 | $1,230.27 |