- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $2,041.74 / $4,365.16
| Facility | | $141.25 | $2,041.74 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $5,248.07
| Facility | 50 | $3,630.78 | $3,630.78 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $169.82 / $398.11
| Professional | | $66.07 | $169.82 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $97.72 / $97.72 / $177.83
| Professional | 50 | $97.72 | $97.72 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $204.17 / $288.40
| Professional | | $144.54 | $204.17 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $190.55 / $288.40
| Professional | | $131.83 | $190.55 | $288.40 |