- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.89 / $3,311.31 / $10,715.19
| Facility | | $125.89 | $3,311.31 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $123.03 / $251.19
| Professional | | $93.33 | $123.03 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $194.98 / $316.23 / $363.08
| Professional | 50 | $194.98 | $316.23 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,715.35 / $9,549.93
| Facility | | $1,513.56 | $3,715.35 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $131.83 / $263.03
| Professional | | $91.20 | $131.83 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $131.83 / $190.55 / $371.54
| Professional | 50 | $131.83 | $190.55 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.12 / $354.81 / $1,023.29
| Facility | | $50.12 | $354.81 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $151.36 / $354.81
| Professional | | $93.33 | $151.36 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $1,122.02 / $3,467.37
| Facility | | $263.03 | $1,122.02 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $120.23 / $229.09
| Professional | | $87.10 | $120.23 | $229.09 |