- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $245.47 / $3,715.35
| Facility | | $239.88 | $245.47 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $158.49 / $281.84
| Professional | | $58.88 | $158.49 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $112.20 / $204.17 / $309.03
| Professional | 50 | $112.20 | $204.17 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $109.65 / $186.21
| Professional | | $50.12 | $109.65 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $131.83 / $302.00
| Professional | | $67.61 | $131.83 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,412.54 / $6,456.54
| Facility | | $316.23 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $109.65 / $263.03
| Professional | | $63.10 | $109.65 | $263.03 |