- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.53 / $2,643.30 / $7,829.16
| Facility | | $172.53 | $2,643.30 | $7,829.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.68 / $128.33 / $175.89
| Professional | | $72.68 | $128.33 | $175.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.48 / $125.46 / $223.97
| Professional | | $72.48 | $125.46 | $223.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.52 / $2,618.33 / $4,467.84
| Facility | | $407.52 | $2,618.33 | $4,467.84 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $8,529.20 / $8,529.20 / $8,529.20
| Facility | 50 | $8,529.20 | $8,529.20 | $8,529.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.73 / $160.62 / $286.44
| Professional | | $122.73 | $160.62 | $286.44 |