- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $177.83 / $331.13
| Professional | | $83.18 | $177.83 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $72.44 / $72.44 / $72.44
| Professional | 50 | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $162.18 / $281.84
| Professional | | $100.00 | $162.18 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $223.87 / $389.05
| Professional | | $134.90 | $223.87 | $389.05 |
- 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
- $107.15 / $177.83 / $309.03
| Professional | | $107.15 | $177.83 | $309.03 |