- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $706.25 / $1,469.82 / $2,678.80
| Facility | | $706.25 | $1,469.82 | $2,678.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,449.90 / $1,611.00 / $3,700.00
| Facility | | $1,449.90 | $1,611.00 | $3,700.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $579.80 / $861.73 / $1,300.20
| Professional | 50 | $579.80 | $861.73 | $1,300.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.36 / $2,000.36 / $2,070.38
| Facility | | $2,000.36 | $2,000.36 | $2,070.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,611.00 / $8,611.00 / $8,611.00
| Facility | | $8,611.00 | $8,611.00 | $8,611.00 |