- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,723.32 / $1,723.32 / $1,723.32
| Facility | | $1,723.32 | $1,723.32 | $1,723.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.05 / $190.29 / $293.00
| Professional | | $139.05 | $190.29 | $293.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.09 / $142.19 / $237.22
| Professional | | $117.09 | $142.19 | $237.22 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $175.63 / $198.70 / $355.83
| Professional | 50 | $175.63 | $198.70 | $355.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.94 / $279.83 / $518.49
| Professional | | $147.94 | $279.83 | $518.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.22 / $307.08 / $493.00
| Professional | | $149.22 | $307.08 | $493.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,723.32 / $1,723.32 / $1,723.32
| Facility | | $1,723.32 | $1,723.32 | $1,723.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.05 / $193.70 / $347.94
| Professional | | $139.05 | $193.70 | $347.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.35 / $222.58 / $505.98
| Professional | | $165.35 | $222.58 | $505.98 |