- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $3,301.91 / $3,301.91 / $3,301.91
| Facility | 50 | $3,301.91 | $3,301.91 | $3,301.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.01 / $555.61 / $1,012.06
| Professional | | $438.01 | $555.61 | $1,012.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.79 / $692.50 / $1,050.43
| Professional | | $548.79 | $692.50 | $1,050.43 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $823.19 / $1,060.35 / $1,575.65
| Professional | 50 | $823.19 | $1,060.35 | $1,575.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.89 / $850.46 / $1,221.38
| Professional | | $487.89 | $850.46 | $1,221.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.31 / $833.79 / $1,290.10
| Professional | | $679.31 | $833.79 | $1,290.10 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $3,301.91 / $3,301.91 / $3,301.91
| Facility | 50 | $3,301.91 | $3,301.91 | $3,301.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.01 / $591.73 / $1,033.32
| Professional | | $438.01 | $591.73 | $1,033.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.75 / $840.23 / $1,265.27
| Professional | | $589.75 | $840.23 | $1,265.27 |