- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.64 / $1,121.08 / $1,336.68
| Facility | | $63.64 | $1,121.08 | $1,336.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.64 / $120.00 / $205.77
| Professional | | $63.64 | $120.00 | $205.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.20 / $76.98 / $141.56
| Professional | | $65.20 | $76.98 | $141.56 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $97.80 / $107.58 / $212.34
| Professional | 50 | $97.80 | $107.58 | $212.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.52 / $157.61 / $284.16
| Professional | | $67.52 | $157.61 | $284.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,278.00 / $1,278.00 / $1,278.00
| Facility | | $1,278.00 | $1,278.00 | $1,278.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.04 / $192.91 / $309.70
| Professional | | $89.04 | $192.91 | $309.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.51 / $292.73 / $1,336.68
| Facility | | $98.51 | $292.73 | $1,336.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.64 / $120.00 / $208.32
| Professional | | $63.64 | $120.00 | $208.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.68 / $175.45 / $311.87
| Professional | | $119.68 | $175.45 | $311.87 |