- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $7,244.36
| Facility | | $2,398.83 | $2,398.83 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $208.93 / $467.74
| Professional | | $112.20 | $208.93 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $181.97 / $338.84
| Professional | | $112.20 | $181.97 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | 50 | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $173.78 / $275.42
| Professional | | $104.71 | $173.78 | $275.42 |