- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,095.83 / $34,670.25 / $38,171.44
| Facility | | $1,095.83 | $34,670.25 | $38,171.44 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $219.17 / $219.17 / $219.17
| Facility | 53 | $219.17 | $219.17 | $219.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.25 / $1,095.83 / $2,459.69
| Professional | | $954.25 | $1,095.83 | $2,459.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.41 / $1,942.70 / $2,295.32
| Professional | | $1,783.41 | $1,942.70 | $2,295.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.09 / $1,648.13 / $2,660.39
| Professional | | $1,272.09 | $1,648.13 | $2,660.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,095.83 / $15,258.47 / $21,820.34
| Facility | | $1,095.83 | $15,258.47 | $21,820.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.24 / $2,065.79 / $2,813.33
| Professional | | $1,177.24 | $2,065.79 | $2,813.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.42 / $2,065.79 / $2,813.33
| Professional | | $1,284.42 | $2,065.79 | $2,813.33 |