- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,889.97 / $1,889.97 / $1,889.97
| Facility | | $1,889.97 | $1,889.97 | $1,889.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.37 / $284.99 / $481.70
| Professional | | $139.37 | $284.99 | $481.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.47 / $189.98 / $289.00
| Professional | | $161.47 | $189.98 | $289.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $242.22 / $284.97 / $433.50
| Professional | 50 | $242.22 | $284.97 | $433.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.49 / $321.20 / $743.41
| Professional | | $182.49 | $321.20 | $743.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.78 / $472.38 / $758.36
| Professional | | $181.78 | $472.38 | $758.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,889.97 / $1,889.97 / $1,889.97
| Facility | | $1,889.97 | $1,889.97 | $1,889.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.11 / $274.44 / $675.91
| Professional | | $149.11 | $274.44 | $675.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.10 / $524.88 / $722.34
| Professional | | $347.10 | $524.88 | $722.34 |