- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,677.35 / $4,677.35
| Facility | | $1,513.56 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $4,786.30 / $9,332.54 / $9,549.93
| Facility | 50 | $4,786.30 | $9,332.54 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $446.68 / $1,412.54
| Professional | | $190.55 | $446.68 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $338.84 / $707.95 / $2,754.23
| Professional | 50 | $338.84 | $707.95 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $389.05 / $724.44
| Professional | | $177.83 | $389.05 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $407.38 / $870.96
| Professional | | $239.88 | $407.38 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $416.87 / $776.25
| Professional | | $218.78 | $416.87 | $776.25 |