- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $660.69 / $1,230.27
| Professional | | $467.74 | $660.69 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $660.69 / $776.25
| Professional | | $398.11 | $660.69 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $602.56 / $977.24 / $1,148.15
| Professional | 50 | $602.56 | $977.24 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $707.95
| Facility | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $912.01 / $1,230.27
| Professional | | $562.34 | $912.01 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $724.44 / $1,122.02
| Professional | | $489.78 | $724.44 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $707.95 / $1,230.27
| Professional | | $457.09 | $707.95 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $707.95 / $1,023.29
| Professional | | $489.78 | $707.95 | $1,023.29 |