- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.07 / $681.07 / $681.07
| Facility | | $681.07 | $681.07 | $681.07 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $6,054.31 / $6,054.31 / $6,054.31
| Facility | 50 | $6,054.31 | $6,054.31 | $6,054.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $849.53 / $1,151.01 / $2,047.29
| Facility | | $849.53 | $1,151.01 | $2,047.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,287.00 / $1,877.65 / $2,691.59
| Facility | | $1,287.00 | $1,877.65 | $2,691.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.66 / $1,230.69 / $1,403.13
| Professional | | $963.66 | $1,230.69 | $1,403.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |