- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,137.96 / $6,918.31
| Facility | | $812.83 | $2,137.96 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $676.08 / $1,258.93
| Professional | | $446.68 | $676.08 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Professional | 50 | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,862.09 / $5,495.41
| Professional | | $467.74 | $1,862.09 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $660.69 / $1,778.28
| Professional | | $436.52 | $660.69 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,047.13 / $1,445.44
| Professional | | $676.08 | $1,047.13 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $10,000.00 / $26,302.68
| Facility | | $2,344.23 | $10,000.00 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $588.84 / $1,380.38
| Professional | | $380.19 | $588.84 | $1,380.38 |