- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $3,981.07
| Facility | | $1,659.59 | $1,659.59 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $338.84 / $851.14
| Professional | | $234.42 | $338.84 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $407.38 / $1,479.11 / $1,949.84
| Professional | 50 | $407.38 | $1,479.11 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $218.78 / $512.86
| Professional | | $162.18 | $218.78 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 54
- Low / Median / High Price
- $131.83 / $173.78 / $416.87
| Professional | 54 | $131.83 | $173.78 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $16.22 / $21.88 / $51.29
| Professional | 55 | $16.22 | $21.88 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $288.40 / $446.68
| Professional | | $169.82 | $288.40 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,454.71 / $6,025.60
| Facility | | $1,348.96 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $316.23 / $407.38
| Professional | | $181.97 | $316.23 | $407.38 |