- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $120.23 / $8,511.38
| Facility | | $91.20 | $120.23 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $120.23 / $186.21
| Professional | | $91.20 | $120.23 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $218.78 / $275.42
| Professional | | $169.82 | $218.78 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $257.04 / $331.13 / $416.87
| Professional | 50 | $257.04 | $331.13 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $190.55 / $323.59
| Professional | | $104.71 | $190.55 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $151.36 / $263.03
| Facility | | $91.20 | $151.36 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $213.80 / $660.69
| Professional | | $131.83 | $213.80 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $1,737.80 / $3,388.44
| Facility | | $269.15 | $1,737.80 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $165.96 / $257.04
| Professional | | $109.65 | $165.96 | $257.04 |