- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,288.25 / $2,041.74
| Facility | | $616.60 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $426.58 / $630.96
| Professional | | $177.83 | $426.58 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Professional | 50 | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $4,677.35
| Facility | | $3,388.44 | $3,388.44 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $239.88 / $676.08
| Professional | | $181.97 | $239.88 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $363.08 / $851.14
| Professional | | $218.78 | $363.08 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $7,079.46
| Facility | | $977.24 | $2,137.96 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $426.58 / $812.83
| Professional | | $169.82 | $426.58 | $812.83 |