- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $671.30 / $8,485.02 / $8,485.02
| Facility | | $671.30 | $8,485.02 | $8,485.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.76 / $715.17 / $904.60
| Professional | | $596.76 | $715.17 | $904.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.93 / $1,655.65 / $2,067.63
| Professional | | $1,347.93 | $1,655.65 | $2,067.63 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $2,021.90 / $2,483.48 / $3,064.77
| Professional | 50 | $2,021.90 | $2,483.48 | $3,064.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.24 / $1,649.82 / $2,568.62
| Professional | | $1,016.24 | $1,649.82 | $2,568.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $671.30 / $954.81 / $2,013.90
| Facility | | $671.30 | $954.81 | $2,013.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.65 / $1,538.07 / $2,158.27
| Professional | | $859.65 | $1,538.07 | $2,158.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.92 / $1,788.07 / $2,158.27
| Professional | | $982.92 | $1,788.07 | $2,158.27 |