- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,388.44 / $6,918.31
| Facility | | $851.14 | $3,388.44 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $676.08 / $1,202.26
| Professional | | $436.52 | $676.08 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $954.99 / $1,230.27 / $1,778.28
| Professional | 50 | $954.99 | $1,230.27 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $1,862.09 / $5,495.41
| Professional | | $478.63 | $1,862.09 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $630.96 / $1,862.09
| Professional | | $426.58 | $630.96 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $1,513.56
| Professional | | $707.95 | $1,047.13 | $1,513.56 |
- 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
- $354.81 / $616.60 / $1,445.44
| Professional | | $354.81 | $616.60 | $1,445.44 |