- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.32 / $603.86 / $8,500.00
| Facility | | $483.32 | $603.86 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.62 / $508.75 / $767.12
| Professional | | $428.62 | $508.75 | $767.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $939.61 / $1,176.31 / $1,383.89
| Professional | | $939.61 | $1,176.31 | $1,383.89 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,383.89 / $1,726.47 / $2,075.84
| Professional | 50 | $1,383.89 | $1,726.47 | $2,075.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.63 / $1,008.19 / $1,575.48
| Professional | | $475.63 | $1,008.19 | $1,575.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.32 / $821.64 / $1,301.08
| Facility | | $483.32 | $821.64 | $1,301.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.52 / $1,069.06 / $1,579.06
| Professional | | $613.52 | $1,069.06 | $1,579.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.00 / $2,545.00 / $2,545.00
| Facility | | $2,545.00 | $2,545.00 | $2,545.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.16 / $945.82 / $1,303.31
| Professional | | $540.16 | $945.82 | $1,303.31 |