- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,258.93 / $3,715.35
| Facility | | $501.19 | $1,258.93 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $112.20 / $239.88
| Professional | | $57.54 | $112.20 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $112.20 / $257.04 / $501.19
| Professional | 50 | $112.20 | $257.04 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $74.13 / $128.82
| Professional | | $50.12 | $74.13 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $112.20 / $158.49
| Professional | | $67.61 | $112.20 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $85.11 / $147.91
| Professional | | $54.95 | $85.11 | $147.91 |