- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $380.19 / $630.96
| Professional | | $234.42 | $380.19 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $363.08 / $524.81
| Professional | | $239.88 | $363.08 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $354.81 / $549.54 / $741.31
| Professional | 50 | $354.81 | $549.54 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $512.86 / $758.58
| Professional | | $316.23 | $512.86 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $501.19 / $776.25
| Professional | | $295.12 | $501.19 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $389.05 / $1,122.02
| Professional | | $245.47 | $389.05 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $478.63 / $776.25
| Professional | | $295.12 | $478.63 | $776.25 |