- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,488.96 / $3,883.87 / $10,518.43
| Facility | | $2,488.96 | $3,883.87 | $10,518.43 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $4,919.02 / $4,919.02 / $4,919.02
| Facility | 50 | $4,919.02 | $4,919.02 | $4,919.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $599.00 / $634.82 / $1,575.38
| Facility | | $599.00 | $634.82 | $1,575.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.61 / $776.95 / $1,013.42
| Professional | | $675.61 | $776.95 | $1,013.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,386.00 / $1,386.00 / $1,386.00
| Facility | | $1,386.00 | $1,386.00 | $1,386.00 |