- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $2,398.83
| Facility | | $1,023.29 | $1,513.56 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $1,621.81 / $5,128.61
| Professional | | $251.19 | $1,621.81 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $3,388.44 / $3,890.45 / $4,073.80
| Professional | 50 | $3,388.44 | $3,890.45 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $1,698.24
| Facility | | $1,047.13 | $1,230.27 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $3,890.45 / $6,918.31
| Professional | | $398.11 | $3,890.45 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $478.63 / $5,248.07
| Professional | | $251.19 | $478.63 | $5,248.07 |
- 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
- $213.80 / $2,454.71 / $5,128.61
| Professional | | $213.80 | $2,454.71 | $5,128.61 |