- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $733.05 / $1,537.50 / $6,278.68
| Facility | | $733.05 | $1,537.50 | $6,278.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.84 / $841.47 / $2,571.65
| Professional | | $254.84 | $841.47 | $2,571.65 |
- Facility/Professional
- Professional
- Modifier
- 53
- Low / Median / High Price
- $50.48 / $86.88 / $103.93
| Professional | 53 | $50.48 | $86.88 | $103.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.00 / $1,006.00 / $1,826.00
| Professional | | $650.00 | $1,006.00 | $1,826.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.47 / $606.47 / $978.73
| Professional | | $349.47 | $606.47 | $978.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.48 / $882.51 / $2,097.48
| Professional | | $508.48 | $882.51 | $2,097.48 |