- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $857.85 / $857.85 / $6,907.00
| Facility | | $857.85 | $857.85 | $6,907.00 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $1,715.70 / $1,715.70 / $1,715.70
| Facility | 50 | $1,715.70 | $1,715.70 | $1,715.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.55 / $162.40 / $229.60
| Professional | | $83.55 | $162.40 | $229.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.82 / $139.66 / $254.01
| Professional | | $95.82 | $139.66 | $254.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.05 / $344.05 / $344.05
| Professional | | $344.05 | $344.05 | $344.05 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $489.15 / $489.15 / $489.15
| Professional | 50 | $489.15 | $489.15 | $489.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.69 / $209.63 / $499.43
| Professional | | $182.69 | $209.63 | $499.43 |