- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,854.66 / $2,854.66 / $6,165.32
| Facility | | $2,854.66 | $2,854.66 | $6,165.32 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $6,166.08 / $6,166.08 / $6,974.87
| Facility | 50 | $6,166.08 | $6,166.08 | $6,974.87 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $98.88 / $148.32 / $178.32
| Professional | 50 | $98.88 | $148.32 | $178.32 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $217.41 / $392.16 / $608.35
| Professional | 50 | $217.41 | $392.16 | $608.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,854.66 / $3,749.70 / $6,165.32
| Facility | | $2,854.66 | $3,749.70 | $6,165.32 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $6,166.08 / $6,166.08 / $6,974.87
| Facility | 50 | $6,166.08 | $6,166.08 | $6,974.87 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $98.88 / $148.32 / $178.32
| Professional | 50 | $98.88 | $148.32 | $178.32 |