- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $304.24 / $3,738.29 / $3,738.29
| Facility | | $304.24 | $3,738.29 | $3,738.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.95 / $705.80 / $1,109.66
| Professional | | $298.95 | $705.80 | $1,109.66 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,388.24 / $1,388.24 / $1,388.24
| Professional | 50 | $1,388.24 | $1,388.24 | $1,388.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.69 / $1,053.33 / $1,815.82
| Professional | | $597.69 | $1,053.33 | $1,815.82 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $896.54 / $1,272.06 / $2,723.73
| Professional | 50 | $896.54 | $1,272.06 | $2,723.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.25 / $928.14 / $1,903.22
| Professional | | $457.25 | $928.14 | $1,903.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $304.24 / $517.21 / $1,289.64
| Facility | | $304.24 | $517.21 | $1,289.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.96 / $1,494.77 / $2,778.63
| Professional | | $847.96 | $1,494.77 | $2,778.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $770.87 / $1,411.73 / $1,695.91
| Professional | | $770.87 | $1,411.73 | $1,695.91 |