- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $112.20 / $263.03
| Professional | | $61.66 | $112.20 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $81.28 / $194.98 / $562.34
| Professional | 50 | $81.28 | $194.98 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,041.74
| Facility | | $1,905.46 | $1,905.46 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $109.65 / $181.97
| Professional | | $67.61 | $109.65 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $131.83 / $162.18
| Professional | | $100.00 | $131.83 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $131.83 / $223.87
| Professional | | $81.28 | $131.83 | $223.87 |