- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,890.45 / $10,471.29
| Facility | | $630.96 | $3,890.45 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $1,047.13 / $4,168.69 / $10,471.29
| Facility | 50 | $1,047.13 | $4,168.69 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $213.80 / $741.31 / $2,754.23
| Professional | 50 | $213.80 | $741.31 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,570.88 / $10,471.29
| Facility | | $2,238.72 | $4,570.88 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $457.09 / $691.83 / $1,412.54
| Professional | 50 | $457.09 | $691.83 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,548.82 / $3,715.35
| Facility | | $676.08 | $1,548.82 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,265.80 / $10,000.00
| Facility | | $1,584.89 | $4,265.80 | $10,000.00 |