- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $6,165.95
| Facility | | $5,011.87 | $5,011.87 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | 50 | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $691.83 / $4,570.88
| Professional | | $467.74 | $691.83 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,819.70 / $1,819.70
| Professional | | $1,202.26 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $933.25 / $1,445.44
| Professional | | $602.56 | $933.25 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,168.69 / $14,125.38
| Facility | | $1,380.38 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $933.25 / $1,995.26
| Professional | | $562.34 | $933.25 | $1,995.26 |