- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,445.44 / $1,862.09
| Facility | | $575.44 | $1,445.44 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $870.96 / $1,318.26
| Professional | | $588.84 | $870.96 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $870.96 / $1,174.90
| Facility | | $724.44 | $870.96 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $758.58 / $831.76
| Professional | | $512.86 | $758.58 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Facility | 54 | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $630.96 / $2,344.23
| Professional | | $446.68 | $630.96 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,698.24 / $3,090.30
| Facility | | $645.65 | $1,698.24 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $616.60 / $812.83
| Professional | | $489.78 | $616.60 | $812.83 |