- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $145.28 / $1,627.23
| Facility | | $0.02 | $145.28 | $1,627.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.29 / $165.07 / $245.37
| Professional | | $54.29 | $165.07 | $245.37 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $88.38 / $88.38 / $212.01
| Professional | 50 | $88.38 | $88.38 | $212.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.25 / $109.66 / $314.49
| Professional | | $61.25 | $109.66 | $314.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.25 / $238.25 / $238.25
| Professional | | $238.25 | $238.25 | $238.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.00 / $143.00 / $143.00
| Facility | | $143.00 | $143.00 | $143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.01 / $226.82 / $386.81
| Professional | | $152.01 | $226.82 | $386.81 |