- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,244.36
| Facility | | $3,235.94 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $100.00 / $251.19
| Professional | | $54.95 | $100.00 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $323.59 / $371.54 / $416.87
| Professional | 50 | $323.59 | $371.54 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $104.71 / $177.83
| Professional | | $52.48 | $104.71 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $5,011.87
| Facility | | $436.52 | $436.52 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $95.50 / $229.09
| Professional | | $54.95 | $95.50 | $229.09 |