- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.67 / $457.65 / $457.65
| Facility | | $391.67 | $457.65 | $457.65 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $3,570.00 / $3,570.00 / $3,570.00
| Professional | 50 | $3,570.00 | $3,570.00 | $3,570.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $488.79 / $672.70 / $1,157.79
| Facility | | $488.79 | $672.70 | $1,157.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $694.00 / $1,074.66 / $1,913.58
| Facility | | $694.00 | $1,074.66 | $1,913.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.31 / $732.21 / $892.72
| Professional | | $476.31 | $732.21 | $892.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |