- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,090.30 / $6,760.83
| Facility | | $1,737.80 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $870.96 / $1,819.70
| Professional | | $147.91 | $870.96 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $794.33 / $4,265.80 / $5,495.41
| Professional | 50 | $794.33 | $4,265.80 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $1,778.28 / $2,691.53
| Facility | | $549.54 | $1,778.28 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $549.54 / $1,479.11
| Professional | | $123.03 | $549.54 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $851.14 / $1,862.09
| Professional | | $154.88 | $851.14 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.88 / $1,047.13 / $3,090.30
| Facility | | $154.88 | $1,047.13 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,230.27 / $3,467.37
| Professional | | $912.01 | $1,230.27 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,995.26 / $4,786.30
| Facility | | $1,288.25 | $1,995.26 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $776.25 / $1,548.82
| Professional | | $141.25 | $776.25 | $1,548.82 |