- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $305.50 / $1,554.20 / $2,500.00
| Facility | | $305.50 | $1,554.20 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.36 / $482.75 / $1,756.94
| Professional | | $277.36 | $482.75 | $1,756.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.40 / $876.16 / $3,913.17
| Professional | | $642.40 | $876.16 | $3,913.17 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $963.60 / $1,367.21 / $5,861.39
| Professional | 50 | $963.60 | $1,367.21 | $5,861.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $555.64 / $555.64 / $555.64
| Facility | | $555.64 | $555.64 | $555.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.54 / $1,380.40 / $4,063.98
| Professional | | $387.54 | $1,380.40 | $4,063.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $395.04 / $1,554.20 / $3,113.51
| Facility | | $395.04 | $1,554.20 | $3,113.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.61 / $3,526.73 / $11,504.00
| Professional | | $1,701.61 | $3,526.73 | $11,504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.73 / $2,850.42 / $4,076.72
| Professional | | $1,567.73 | $2,850.42 | $4,076.72 |