- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $1,862.09 / $4,073.80
| Facility | | $281.84 | $1,862.09 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $309.03 / $1,174.90
| Professional | | $128.82 | $309.03 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $371.54 / $1,096.48 / $1,698.24
| Professional | 50 | $371.54 | $1,096.48 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $309.03 / $2,454.71
| Professional | | $144.54 | $309.03 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $281.84 / $645.65
| Professional | | $120.23 | $281.84 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $323.59 / $616.60
| Professional | | $295.12 | $323.59 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,737.80 / $5,128.61
| Facility | | $741.31 | $1,737.80 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $257.04 / $602.56
| Professional | | $117.49 | $257.04 | $602.56 |