- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,706.14 / $7,745.00
| Facility | | $2,090.73 | $3,706.14 | $7,745.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.46 / $764.00 / $1,958.28
| Professional | | $211.46 | $764.00 | $1,958.28 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,557.00 / $2,355.91 / $2,546.46
| Professional | 50 | $1,557.00 | $2,355.91 | $2,546.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.79 / $798.19 / $2,992.64
| Professional | | $428.79 | $798.19 | $2,992.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.34 / $836.04 / $3,308.33
| Professional | | $358.34 | $836.04 | $3,308.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.05 / $2,120.62 / $3,853.66
| Professional | | $1,597.05 | $2,120.62 | $3,853.66 |