- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $371.54 / $1,148.15
| Professional | | $288.40 | $371.54 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,659.59 / $1,698.24 / $1,819.70
| Professional | 50 | $1,659.59 | $1,698.24 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $691.83 / $870.96
| Facility | | $645.65 | $691.83 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $549.54 / $1,202.26
| Professional | | $467.74 | $549.54 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $489.78 / $588.84
| Professional | | $288.40 | $489.78 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $1,202.26
| Professional | | $562.34 | $562.34 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $407.38 / $1,288.25
| Professional | | $323.59 | $407.38 | $1,288.25 |