- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,715.35
| Facility | | $2,570.40 | $2,570.40 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $234.42 / $912.01
| Professional | | $107.15 | $234.42 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $338.84 / $478.63 / $1,479.11
| Professional | 50 | $338.84 | $478.63 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- 53
- Low / Median / High Price
- $186.21 / $186.21 / $186.21
| Professional | 53 | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,479.11 / $1,949.84
| Facility | | $1,348.96 | $1,479.11 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $912.01
| Professional | | $407.38 | $407.38 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $204.17 / $501.19
| Professional | | $128.82 | $204.17 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 53
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Professional | 53 | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $323.59 / $416.87
| Professional | | $245.47 | $323.59 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 53
- Low / Median / High Price
- $123.03 / $162.18 / $208.93
| Professional | 53 | $123.03 | $162.18 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $323.59 / $562.34
| Professional | | $134.90 | $323.59 | $562.34 |