- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,754.23 / $11,481.54
| Facility | | $1,348.96 | $2,754.23 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $741.31 / $954.99 / $1,548.82
| Professional | 50 | $741.31 | $954.99 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,737.80 / $3,019.95
| Facility | | $1,584.89 | $1,737.80 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $588.84 / $1,174.90 / $1,659.59
| Professional | 50 | $588.84 | $1,174.90 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $9,549.93
| Facility | | $9,549.93 | $9,549.93 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $9,549.93
| Facility | | $9,549.93 | $9,549.93 | $9,549.93 |