- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $1,230.27 / $2,041.74
| Facility | | $457.09 | $1,230.27 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $562.34 / $562.34 / $3,090.30
| Professional | 50 | $562.34 | $562.34 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Professional | 50 | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,398.83
| Facility | | $1,737.80 | $1,737.80 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $707.95 / $707.95 / $707.95
| Professional | 50 | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,445.44 / $4,365.16
| Facility | | $588.84 | $1,445.44 | $4,365.16 |