- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $597.48 / $743.29 / $8,500.00
| Facility | | $597.48 | $743.29 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.87 / $630.36 / $798.18
| Professional | | $488.87 | $630.36 | $798.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.82 / $1,441.96 / $1,696.42
| Professional | | $1,163.82 | $1,441.96 | $1,696.42 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,745.73 / $2,116.35 / $2,544.63
| Professional | 50 | $1,745.73 | $2,116.35 | $2,544.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.41 / $1,234.75 / $1,929.52
| Professional | | $568.41 | $1,234.75 | $1,929.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $597.48 / $992.05 / $1,594.68
| Facility | | $597.48 | $992.05 | $1,594.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.49 / $1,319.42 / $1,943.84
| Professional | | $679.49 | $1,319.42 | $1,943.84 |
- 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
- $679.49 / $1,172.82 / $1,750.37
| Professional | | $679.49 | $1,172.82 | $1,750.37 |