- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,301.55 / $3,301.55 / $3,301.55
| Facility | | $3,301.55 | $3,301.55 | $3,301.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.26 / $616.52 / $922.60
| Professional | | $400.26 | $616.52 | $922.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.27 / $583.85 / $769.92
| Professional | | $496.27 | $583.85 | $769.92 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $744.41 / $875.78 / $1,154.88
| Professional | 50 | $744.41 | $875.78 | $1,154.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.23 / $814.23 / $814.23
| Facility | | $814.23 | $814.23 | $814.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.30 / $919.20 / $1,173.11
| Professional | | $690.30 | $919.20 | $1,173.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.12 / $720.53 / $1,121.14
| Professional | | $558.12 | $720.53 | $1,121.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,301.55 / $3,301.55 / $3,301.55
| Facility | | $3,301.55 | $3,301.55 | $3,301.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.26 / $561.44 / $896.95
| Professional | | $400.26 | $561.44 | $896.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.37 / $791.53 / $1,023.53
| Professional | | $556.37 | $791.53 | $1,023.53 |