- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,461.21 / $7,068.88 / $12,332.18
| Facility | | $1,461.21 | $7,068.88 | $12,332.18 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $8,304.20 / $8,304.20 / $8,304.20
| Facility | 50 | $8,304.20 | $8,304.20 | $8,304.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,040.18 / $5,040.18 / $5,040.18
| Facility | | $5,040.18 | $5,040.18 | $5,040.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.83 / $1,531.95 / $2,575.05
| Professional | | $1,151.83 | $1,531.95 | $2,575.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,882.00 / $2,882.00 / $2,882.00
| Facility | | $2,882.00 | $2,882.00 | $2,882.00 |