- 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
- $85.11 / $128.82 / $263.03
| Professional | | $85.11 | $128.82 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $138.04 / $204.17
| Professional | | $81.28 | $138.04 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $128.82 / $204.17 / $309.03
| Professional | 50 | $128.82 | $204.17 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $162.18 / $229.09
| Professional | | $112.20 | $162.18 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $154.88 / $245.47
| Professional | | $95.50 | $154.88 | $245.47 |
- 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
- $85.11 / $131.83 / $331.13
| Professional | | $85.11 | $131.83 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $154.88 / $245.47
| Professional | | $100.00 | $154.88 | $245.47 |