- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Facility | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $128.82 / $263.03
| Professional | | $107.15 | $128.82 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $173.78 / $190.55 / $194.98
| Professional | 50 | $173.78 | $190.55 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $416.87
| Facility | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $109.65 / $204.17
| Professional | | $100.00 | $109.65 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $134.90 / $138.04
| Professional | | $134.90 | $134.90 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $120.23 / $151.36
| Professional | | $100.00 | $120.23 | $151.36 |