- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $6,025.60 / $7,943.28
| Facility | | $1,348.96 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $977.24 / $2,089.30
| Professional | | $549.54 | $977.24 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,290.87 / $7,079.46
| Facility | | $1,230.27 | $2,290.87 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $4,570.88
| Facility | 54 | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,778.28 / $2,041.74
| Professional | | $1,230.27 | $1,778.28 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,754.40 / $7,585.78
| Facility | | $3,311.31 | $5,754.40 | $7,585.78 |