- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $1,288.25 / $2,041.74
| Facility | | $190.55 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $229.09 / $338.84
| Professional | | $147.91 | $229.09 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $363.08 / $363.08 / $398.11
| Professional | 50 | $363.08 | $363.08 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,238.72
| Facility | | $1,621.81 | $1,621.81 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $194.98 / $380.19
| Professional | | $147.91 | $194.98 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $288.40 / $457.09
| Professional | | $181.97 | $288.40 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,445.44 / $5,011.87
| Facility | | $602.56 | $1,445.44 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $257.04 / $446.68
| Professional | | $138.04 | $257.04 | $446.68 |