- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.91 / $1,569.31 / $4,926.79
| Facility | | $326.91 | $1,569.31 | $4,926.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.36 / $482.75 / $1,917.03
| Professional | | $277.36 | $482.75 | $1,917.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.65 / $1,065.83 / $2,521.69
| Professional | | $357.65 | $1,065.83 | $2,521.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,660.85 / $3,660.85 / $3,862.20
| Facility | | $3,660.85 | $3,660.85 | $3,862.20 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $7,321.17 / $7,321.17 / $7,321.17
| Facility | 50 | $7,321.17 | $7,321.17 | $7,321.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.10 / $567.10 / $567.10
| Professional | | $567.10 | $567.10 | $567.10 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $806.28 / $806.28 / $806.28
| Professional | 50 | $806.28 | $806.28 | $806.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.48 / $2,057.54 / $3,539.93
| Professional | | $1,485.48 | $2,057.54 | $3,539.93 |