- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,929.42 / $3,929.42 / $3,929.42
| Facility | | $3,929.42 | $3,929.42 | $3,929.42 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $0.98 / $0.98 / $0.98
| Facility | 50 | $0.98 | $0.98 | $0.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,745.52 / $1,745.52 / $1,745.52
| Facility | | $1,745.52 | $1,745.52 | $1,745.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.71 / $629.15 / $1,037.82
| Professional | | $487.71 | $629.15 | $1,037.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,897.94 / $6,897.94 / $6,897.94
| Facility | | $6,897.94 | $6,897.94 | $6,897.94 |