- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $355.94 / $5,086.37 / $8,606.77
| Facility | | $355.94 | $5,086.37 | $8,606.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.80 / $355.95 / $378.47
| Professional | | $349.80 | $355.95 | $378.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.55 / $446.05 / $616.50
| Professional | | $318.55 | $446.05 | $616.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,113.20 / $6,169.74 / $17,611.80
| Facility | | $5,113.20 | $6,169.74 | $17,611.80 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $17,016.28 / $17,016.28 / $17,016.28
| Facility | 50 | $17,016.28 | $17,016.28 | $17,016.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.68 / $449.85 / $807.56
| Professional | | $298.68 | $449.85 | $807.56 |