- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,754.23 / $3,090.30
| Facility | | $1,513.56 | $2,754.23 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $0.98 / $1,380.38 / $3,388.44
| Facility | 50 | $0.98 | $1,380.38 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $380.19 / $691.83
| Professional | | $331.13 | $380.19 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |