- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,277.00 / $6,066.00 / $12,688.52
| Facility | | $4,277.00 | $6,066.00 | $12,688.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.83 / $939.16 / $2,276.78
| Professional | | $600.83 | $939.16 | $2,276.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $852.73 / $1,657.81 / $14,731.00
| Facility | | $852.73 | $1,657.81 | $14,731.00 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $6,350.80 / $6,350.80 / $6,350.80
| Facility | 53 | $6,350.80 | $6,350.80 | $6,350.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $964.98 / $1,399.22 / $1,717.98
| Facility | | $964.98 | $1,399.22 | $1,717.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,604.00 / $13,476.00 / $23,884.54
| Facility | | $8,604.00 | $13,476.00 | $23,884.54 |