- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,137.96
| Facility | | $2,041.74 | $2,041.74 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $4,265.80
| Facility | 50 | $2,137.96 | $2,137.96 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $338.84 / $870.96
| Professional | | $104.71 | $338.84 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $446.68 / $512.86 / $3,019.95
| Professional | 50 | $446.68 | $512.86 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $229.09 / $912.01
| Professional | | $95.50 | $229.09 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $147.91 / $346.74 / $1,380.38
| Professional | 50 | $147.91 | $346.74 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $218.78 / $1,122.02
| Professional | | $131.83 | $218.78 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $616.60 / $1,071.52
| Professional | | $109.65 | $616.60 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,137.96
| Facility | | $2,041.74 | $2,041.74 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $4,265.80
| Facility | 50 | $2,137.96 | $2,137.96 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $371.54 / $1,380.38
| Professional | | $104.71 | $371.54 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $446.68 / $512.86 / $3,019.95
| Professional | 50 | $446.68 | $512.86 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $457.09 / $1,096.48
| Professional | | $123.03 | $457.09 | $1,096.48 |