- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $3,981.07
| Facility | | $1,949.84 | $1,949.84 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $117.49 / $389.05
| Professional | | $56.23 | $117.49 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $338.84 / $363.08 / $1,071.52
| Professional | 50 | $338.84 | $363.08 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $107.15 / $190.55
| Professional | | $58.88 | $107.15 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $117.49 / $190.55
| Professional | | $77.62 | $117.49 | $190.55 |
- 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
- $54.95 / $97.72 / $194.98
| Professional | | $54.95 | $97.72 | $194.98 |