- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,870.55 / $3,301.55 / $3,301.55
| Facility | | $1,870.55 | $3,301.55 | $3,301.55 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $2,555.48 / $2,555.48 / $2,634.44
| Facility | 50 | $2,555.48 | $2,555.48 | $2,634.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.81 / $1,141.54 / $2,325.42
| Professional | | $297.81 | $1,141.54 | $2,325.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.88 / $889.89 / $2,293.81
| Professional | | $360.88 | $889.89 | $2,293.81 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $541.32 / $1,334.83 / $3,440.72
| Professional | 50 | $541.32 | $1,334.83 | $3,440.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.00 / $708.46 / $3,283.21
| Professional | | $375.00 | $708.46 | $3,283.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.03 / $1,092.53 / $2,962.31
| Professional | | $359.03 | $1,092.53 | $2,962.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,870.55 / $3,301.55 / $55,632.50
| Facility | | $1,870.55 | $3,301.55 | $55,632.50 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $2,555.48 / $2,555.48 / $2,634.44
| Facility | 50 | $2,555.48 | $2,555.48 | $2,634.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.29 / $1,141.54 / $2,421.69
| Professional | | $305.29 | $1,141.54 | $2,421.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.15 / $2,378.51 / $2,962.31
| Professional | | $1,560.15 | $2,378.51 | $2,962.31 |