- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $588.84 / $1,122.02
| Professional | | $398.11 | $588.84 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Professional | 50 | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $616.60 / $724.44
| Professional | | $371.54 | $616.60 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $562.34 / $912.01 / $1,071.52
| Professional | 50 | $562.34 | $912.01 | $1,071.52 |
- 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
- $524.81 / $851.14 / $1,071.52
| Professional | | $524.81 | $851.14 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $676.08 / $1,047.13
| Professional | | $467.74 | $676.08 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $645.65 / $1,122.02
| Professional | | $389.05 | $645.65 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,862.09
| Professional | 50 | $1,584.89 | $1,584.89 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $645.65 / $891.25
| Professional | | $457.09 | $645.65 | $891.25 |