- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $876.60 / $5,681.57 / $12,261.08
| Facility | | $876.60 | $5,681.57 | $12,261.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.55 / $323.77 / $1,619.55
| Professional | | $235.55 | $323.77 | $1,619.55 |
- Facility/Professional
- Professional
- Modifier
- 53
- Low / Median / High Price
- $47.11 / $57.68 / $284.83
| Professional | 53 | $47.11 | $57.68 | $284.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.35 / $445.59 / $1,919.61
| Professional | | $261.35 | $445.59 | $1,919.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.99 / $493.79 / $2,424.94
| Professional | | $291.99 | $493.79 | $2,424.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,824.00 / $3,824.00 / $3,824.00
| Facility | | $3,824.00 | $3,824.00 | $3,824.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.07 / $659.82 / $2,393.64
| Professional | | $286.07 | $659.82 | $2,393.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $932.73 / $5,783.52 / $12,946.69
| Facility | | $932.73 | $5,783.52 | $12,946.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.55 / $368.93 / $1,639.60
| Professional | | $235.55 | $368.93 | $1,639.60 |
- Facility/Professional
- Professional
- Modifier
- 53
- Low / Median / High Price
- $47.11 / $57.68 / $284.83
| Professional | 53 | $47.11 | $57.68 | $284.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.57 / $614.55 / $2,697.37
| Professional | | $403.57 | $614.55 | $2,697.37 |