- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.86 / $2,000.00 / $2,856.82
| Facility | | $171.86 | $2,000.00 | $2,856.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.36 / $822.48 / $1,070.34
| Professional | | $163.36 | $822.48 | $1,070.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.97 / $1,174.36 / $1,846.49
| Professional | | $337.97 | $1,174.36 | $1,846.49 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $506.96 / $656.09 / $2,769.74
| Professional | 50 | $506.96 | $656.09 | $2,769.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.51 / $501.07 / $2,020.30
| Professional | | $220.51 | $501.07 | $2,020.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.86 / $894.37 / $1,520.43
| Facility | | $171.86 | $894.37 | $1,520.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.41 / $1,640.72 / $2,348.56
| Professional | | $904.41 | $1,640.72 | $2,348.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.45 / $1,640.72 / $2,348.56
| Professional | | $945.45 | $1,640.72 | $2,348.56 |