- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $2,630.27 / $4,786.30
| Facility | | $426.58 | $2,630.27 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $426.58 / $1,148.15
| Professional | | $190.55 | $426.58 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $93.33 / $257.04 / $426.58
| Professional | 52 | $93.33 | $257.04 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 53
- Low / Median / High Price
- $93.33 / $128.82 / $162.18
| Professional | 53 | $93.33 | $128.82 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $562.34 / $1,047.13
| Professional | | $380.19 | $562.34 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $562.34 / $1,148.15
| Professional | | $281.84 | $562.34 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $758.58 / $2,238.72
| Facility | | $239.88 | $758.58 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $489.78 / $1,621.81
| Professional | | $234.42 | $489.78 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $2,290.87 / $3,388.44
| Facility | | $676.08 | $2,290.87 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $426.58 / $831.76
| Professional | | $208.93 | $426.58 | $831.76 |