- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $5,754.40
| Facility | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $489.78 / $1,949.84
| Professional | | $173.78 | $489.78 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $524.81 / $2,137.96
| Professional | | $467.74 | $524.81 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $389.05 / $660.69 / $3,162.28
| Professional | 50 | $389.05 | $660.69 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $407.38 / $1,949.84
| Professional | | $239.88 | $407.38 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $3,090.30
| Facility | | $295.12 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $707.95 / $2,818.38
| Professional | | $281.84 | $707.95 | $2,818.38 |