- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $2,464.00 / $4,975.00
| Facility | | $1,017.00 | $2,464.00 | $4,975.00 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $1,884.50 / $4,001.00 / $5,653.50
| Facility | 50 | $1,884.50 | $4,001.00 | $5,653.50 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $89.28 / $535.67 / $714.24
| Professional | 50 | $89.28 | $535.67 | $714.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $443.83 / $983.77 / $983.77
| Professional | | $443.83 | $983.77 | $983.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,832.00 / $2,343.00 / $26,408.00
| Facility | | $1,832.00 | $2,343.00 | $26,408.00 |