- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $7,244.36
| Facility | | $6,025.60 | $6,025.60 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $9,549.93
| Facility | 50 | $9,549.93 | $9,549.93 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $660.69 / $1,445.44
| Professional | | $524.81 | $660.69 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $251.19 / $831.76 / $2,398.83
| Professional | 50 | $251.19 | $831.76 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $630.96 / $1,047.13
| Professional | | $478.63 | $630.96 | $1,047.13 |
- 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
- $467.74 / $616.60 / $851.14
| Professional | | $467.74 | $616.60 | $851.14 |