- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.44 / $3,311.31 / $6,025.60
| Facility | | $72.44 | $3,311.31 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $169.82 / $416.87
| Professional | | $72.44 | $169.82 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $316.23 / $316.23 / $512.86
| Professional | 50 | $316.23 | $316.23 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $138.04 / $263.03
| Professional | | $87.10 | $138.04 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,630.78 / $7,943.28
| Facility | | $1,122.02 | $3,630.78 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $169.82 / $257.04
| Professional | | $77.62 | $169.82 | $257.04 |