- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $831.76 / $1,949.84
| Professional | | $602.56 | $831.76 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,174.90 / $4,265.80 / $4,677.35
| Professional | 50 | $1,174.90 | $4,265.80 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $660.69 / $1,047.13
| Professional | | $489.78 | $660.69 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $741.31 / $1,348.96
| Professional | | $489.78 | $741.31 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $7,585.78
| Facility | | $2,570.40 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $741.31 / $1,148.15
| Professional | | $478.63 | $741.31 | $1,148.15 |