- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,697.14 / $9,577.00 / $14,552.94
| Facility | | $1,697.14 | $9,577.00 | $14,552.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.76 / $585.97 / $3,259.70
| Professional | | $402.76 | $585.97 | $3,259.70 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $503.60 / $1,523.88 / $1,897.00
| Professional | 50 | $503.60 | $1,523.88 | $1,897.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.48 / $943.48 / $1,917.73
| Professional | | $943.48 | $943.48 | $1,917.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.61 / $725.34 / $4,661.37
| Facility | | $582.61 | $725.34 | $4,661.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.58 / $1,594.12 / $3,130.75
| Professional | | $1,155.58 | $1,594.12 | $3,130.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,717.50 / $2,255.55 / $3,102.75
| Professional | | $1,717.50 | $2,255.55 | $3,102.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $702.65 / $894.43 / $4,661.37
| Facility | | $702.65 | $894.43 | $4,661.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.65 / $2,255.55 / $3,151.02
| Professional | | $652.65 | $2,255.55 | $3,151.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.52 / $1,534.18 / $4,645.74
| Professional | | $754.52 | $1,534.18 | $4,645.74 |