- 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
- $234.42 / $363.08 / $1,148.15
| Professional | | $234.42 | $363.08 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,778.28
| Professional | 50 | $1,698.24 | $1,698.24 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $831.76 / $977.24
| Facility | | $758.58 | $831.76 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $676.08 / $1,096.48
| Professional | | $575.44 | $676.08 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $457.09 / $758.58
| Professional | | $323.59 | $457.09 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $1,096.48
| Professional | | $501.19 | $501.19 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $467.74 / $977.24
| Professional | | $288.40 | $467.74 | $977.24 |