- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,391.85 / $10,175.36 / $13,413.92
| Facility | | $1,391.85 | $10,175.36 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.11 / $1,842.84 / $2,673.34
| Professional | | $598.11 | $1,842.84 | $2,673.34 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,144.16 / $1,144.16 / $1,144.16
| Professional | 50 | $1,144.16 | $1,144.16 | $1,144.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.65 / $1,128.65 / $1,650.15
| Professional | | $1,128.65 | $1,128.65 | $1,650.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $403.02 / $2,579.98 / $3,742.68
| Facility | | $403.02 | $2,579.98 | $3,742.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.10 / $2,062.19 / $3,207.33
| Professional | | $794.10 | $2,062.19 | $3,207.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.30 / $1,977.50 / $3,624.75
| Professional | | $1,320.30 | $1,977.50 | $3,624.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $403.02 / $2,579.98 / $3,742.68
| Facility | | $403.02 | $2,579.98 | $3,742.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.83 / $1,977.50 / $5,049.00
| Professional | | $731.83 | $1,977.50 | $5,049.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.12 / $1,980.18 / $4,577.09
| Professional | | $1,320.12 | $1,980.18 | $4,577.09 |