- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,244.36
| Facility | | $3,235.94 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $208.93 / $562.34
| Professional | | $77.62 | $208.93 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $229.09 / $229.09 / $229.09
| Professional | 50 | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $151.36 / $338.84
| Professional | | $69.18 | $151.36 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $5,011.87
| Facility | | $436.52 | $436.52 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $158.49 / $302.00
| Professional | | $70.79 | $158.49 | $302.00 |