- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,128.61 / $6,918.31
| Facility | | $1,412.54 | $5,128.61 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $3,311.31 / $7,585.78
| Professional | | $275.42 | $3,311.31 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $14,125.38 / $14,125.38 / $14,791.08
| Professional | 50 | $14,125.38 | $14,125.38 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $6,309.57 / $37,153.52
| Professional | | $263.03 | $6,309.57 | $37,153.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $2,511.89 / $8,128.31
| Professional | | $263.03 | $2,511.89 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,467.37 / $8,128.31
| Professional | | $3,311.31 | $3,467.37 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $16,218.10 / $33,884.42
| Facility | | $3,311.31 | $16,218.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $707.95 / $8,317.64
| Professional | | $239.88 | $707.95 | $8,317.64 |