- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,623.41 / $5,623.41
| Facility | | $1,513.56 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.91 / $93.33 / $380.19
| Professional | | $22.91 | $93.33 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $208.93 / $208.93 / $208.93
| Professional | 50 | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.39 / $30.90 / $79.43
| Professional | | $22.39 | $30.90 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $56.23 / $426.58
| Professional | | $30.20 | $56.23 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,454.71 / $6,025.60
| Facility | | $1,380.38 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.30 / $63.10 / $309.03
| Professional | | $26.30 | $63.10 | $309.03 |