- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $3,162.28 / $7,413.10
| Facility | | $831.76 | $3,162.28 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $1,778.28 / $3,235.94 / $7,079.46
| Facility | 50 | $1,778.28 | $3,235.94 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,467.37 / $9,772.37
| Facility | | $1,230.27 | $3,467.37 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $7,244.36 / $9,772.37
| Facility | | $4,168.69 | $7,244.36 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $407.38 / $1,348.96
| Professional | | $323.59 | $407.38 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 22
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Professional | 22 | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,791.08 / $22,908.68 / $26,915.35
| Facility | | $14,791.08 | $22,908.68 | $26,915.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,754.40 / $8,511.38
| Facility | | $1,513.56 | $5,754.40 | $8,511.38 |