- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,090.30 / $6,760.83
| Facility | | $630.96 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | 50 | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,000.00 / $6,165.95
| Professional | | $660.69 | $1,000.00 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $5,370.32 / $16,218.10
| Facility | | $954.99 | $5,370.32 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $2,238.72
| Professional | | $1,380.38 | $1,862.09 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,481.54 / $21,379.62
| Facility | | $7,413.10 | $11,481.54 | $21,379.62 |