- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $1,513.56 / $2,570.40
| Facility | | $363.08 | $1,513.56 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $1,819.70 / $2,290.87 / $6,760.83
| Facility | 50 | $1,819.70 | $2,290.87 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Professional | 50 | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $3,388.44
| Facility | | $1,445.44 | $1,445.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,691.53 / $6,606.93
| Facility | | $724.44 | $2,691.53 | $6,606.93 |