- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $1,258.93 / $2,398.83
| Facility | | $707.95 | $1,258.93 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $707.95 / $1,513.56
| Professional | | $457.09 | $707.95 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,786.30 / $6,456.54
| Facility | | $3,981.07 | $4,786.30 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $6,025.60 / $7,079.46 / $9,549.93
| Facility | 50 | $6,025.60 | $7,079.46 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,258.93
| Professional | | $707.95 | $1,000.00 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $676.08 / $1,288.25
| Professional | | $467.74 | $676.08 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,951.21 / $4,365.16
| Facility | | $831.76 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $588.84 / $1,000.00
| Professional | | $398.11 | $588.84 | $1,000.00 |