- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $2,630.27 / $6,760.83
| Facility | | $457.09 | $2,630.27 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $239.88 / $562.34 / $3,630.78
| Professional | 50 | $239.88 | $562.34 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,754.40 / $9,120.11
| Facility | | $3,715.35 | $5,754.40 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $562.34 / $3,981.07
| Facility | | $407.38 | $562.34 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,995.26 / $3,981.07
| Facility | | $575.44 | $1,995.26 | $3,981.07 |