- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,244.36
| Facility | | $3,235.94 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $457.09 / $1,202.26
| Professional | | $234.42 | $457.09 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $676.08 / $676.08 / $1,862.09
| Professional | 50 | $676.08 | $676.08 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $416.87
| Facility | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $426.58 / $512.86
| Professional | | $194.98 | $426.58 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $239.88 / $251.19
| Professional | | $239.88 | $239.88 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | 50 | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $457.09 / $602.56
| Professional | | $371.54 | $457.09 | $602.56 |