- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $3,090.30 / $5,011.87
| Facility | | $758.58 | $3,090.30 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $2,570.40 / $5,128.61 / $7,762.47
| Facility | 50 | $2,570.40 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $851.14 / $1,445.44
| Professional | | $741.31 | $851.14 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |