- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,715.35 / $6,165.95
| Facility | | $2,884.03 | $3,715.35 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $6,918.31
| Facility | 50 | $6,165.95 | $6,165.95 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $100.00 / $177.83 / $831.76
| Professional | 50 | $100.00 | $177.83 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $190.55 / $389.05 / $691.83
| Professional | 50 | $190.55 | $389.05 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,715.35 / $6,165.95
| Facility | | $2,884.03 | $3,715.35 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $6,918.31
| Facility | 50 | $6,165.95 | $6,165.95 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $100.00 / $177.83 / $831.76
| Professional | 50 | $100.00 | $177.83 | $831.76 |