- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $309.03 / $1,230.27
| Professional | | $169.82 | $309.03 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,584.89 / $1,819.70 / $1,905.46
| Professional | 50 | $1,584.89 | $1,819.70 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $354.81 / $575.44
| Professional | | $123.03 | $354.81 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $354.81 / $691.83
| Professional | | $208.93 | $354.81 | $691.83 |