- 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
- $22.91 / $53.70 / $251.19
| Professional | | $22.91 | $53.70 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $109.65 / $109.65 / $208.93
| Professional | 50 | $109.65 | $109.65 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.88 / $97.72 / $257.04
| Professional | | $21.88 | $97.72 | $257.04 |
- 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
- $28.18 / $91.20 / $331.13
| Professional | | $28.18 | $91.20 | $331.13 |