- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,370.32 / $7,943.28
| Facility | | $1,380.38 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,412.54 / $2,951.21
| Professional | | $794.33 | $1,412.54 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,548.82 / $3,388.44
| Facility | | $831.76 | $1,548.82 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | 52 | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,905.46 / $2,290.87
| Professional | | $1,445.44 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,897.79 / $7,413.10
| Facility | | $1,318.26 | $4,897.79 | $7,413.10 |