- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,548.13 / $5,248.07
| Facility | | $2,630.27 | $3,548.13 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | 50 | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $363.08 / $562.34
| Professional | | $208.93 | $363.08 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $114.82 / $724.44 / $933.25
| Professional | 50 | $114.82 | $724.44 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $338.84 / $575.44
| Professional | | $190.55 | $338.84 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $5,370.32
| Facility | | $4,897.79 | $4,897.79 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | 50 | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,905.46
| Professional | | $1,819.70 | $1,819.70 | $1,905.46 |
- 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
- $204.17 / $323.59 / $501.19
| Professional | | $204.17 | $323.59 | $501.19 |