- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,370.32 / $7,943.28
| Facility | | $1,202.26 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,570.40 / $4,677.35
| Facility | | $1,047.13 | $2,570.40 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,318.26 / $1,659.59
| Facility | | $776.25 | $1,318.26 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $954.99 / $5,370.32
| Professional | | $660.69 | $954.99 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- 54
- Low / Median / High Price
- $812.83 / $812.83 / $1,288.25
| Professional | 54 | $812.83 | $812.83 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,981.07 / $6,918.31
| Facility | | $1,122.02 | $3,981.07 | $6,918.31 |