- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $691.83 / $1,479.11
| Professional | | $467.74 | $691.83 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $724.44 / $954.99 / $1,513.56
| Professional | 50 | $724.44 | $954.99 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $478.63 / $588.84
| Professional | | $426.58 | $478.63 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $630.96 / $1,023.29
| Facility | | $602.56 | $630.96 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $575.44 / $1,148.15
| Professional | | $398.11 | $575.44 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $758.58 / $1,122.02
| Professional | | $616.60 | $758.58 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,621.81
| Facility | | $1,000.00 | $1,000.00 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $537.03 / $977.24
| Professional | | $371.54 | $537.03 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $724.44 / $1,071.52
| Professional | | $363.08 | $724.44 | $1,071.52 |