- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $1,995.26 / $8,317.64
| Facility | | $575.44 | $1,995.26 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $5,011.87 / $6,456.54 / $8,317.64
| Facility | 50 | $5,011.87 | $6,456.54 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,365.16 / $10,232.93
| Facility | | $3,630.78 | $4,365.16 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $831.76 / $1,698.24
| Professional | | $389.05 | $831.76 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,630.78 / $7,079.46
| Facility | | $1,584.89 | $3,630.78 | $7,079.46 |