- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $1,000.00 / $2,691.53
| Professional | | $158.49 | $1,000.00 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | 50 | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $912.01 / $1,047.13 / $1,096.48
| Professional | 50 | $912.01 | $1,047.13 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,162.28 / $4,265.80
| Facility | | $2,691.53 | $3,162.28 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,479.11 / $2,290.87
| Professional | | $151.36 | $1,479.11 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $338.84 / $2,818.38
| Professional | | $154.88 | $338.84 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,630.78 / $5,128.61
| Facility | | $1,096.48 | $3,630.78 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $1,288.25 / $2,818.38
| Professional | | $131.83 | $1,288.25 | $2,818.38 |