- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $891.25 / $1,737.80
| Facility | | $147.91 | $891.25 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $97.72 / $204.17
| Professional | | $57.54 | $97.72 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $177.83 / $204.17 / $426.58
| Professional | 50 | $177.83 | $204.17 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $87.10 / $87.10
| Professional | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,412.54 / $1,905.46
| Facility | | $1,174.90 | $1,412.54 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $102.33 / $134.90
| Professional | | $67.61 | $102.33 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $104.71 / $199.53
| Professional | | $64.57 | $104.71 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $588.84 / $1,548.82
| Facility | | $251.19 | $588.84 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $83.18 / $177.83
| Professional | | $50.12 | $83.18 | $177.83 |