- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,949.84 / $4,570.88
| Facility | | $616.60 | $1,949.84 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $5,888.44 / $8,128.31 / $13,803.84
| Facility | 50 | $5,888.44 | $8,128.31 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $100.00 / $616.60 / $1,513.56
| Professional | 50 | $100.00 | $616.60 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Professional | 50 | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,981.07 / $5,888.44
| Facility | | $2,344.23 | $3,981.07 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $3,388.44 / $3,388.44
| Facility | | $39.81 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,630.27 / $6,606.93
| Facility | | $831.76 | $2,630.27 | $6,606.93 |