- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | 50 | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $204.17 / $354.81
| Professional | | $138.04 | $204.17 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,047.13 / $1,071.52 / $1,122.02
| Professional | 50 | $1,047.13 | $1,071.52 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $389.05 / $812.83
| Professional | | $323.59 | $389.05 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $257.04 / $363.08
| Professional | | $194.98 | $257.04 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $812.83
| Professional | | $371.54 | $371.54 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $251.19 / $602.56
| Professional | | $165.96 | $251.19 | $602.56 |