- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,736.00 / $4,736.00 / $6,907.00
| Facility | | $4,736.00 | $4,736.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.90 / $173.00 / $220.45
| Professional | | $111.90 | $173.00 | $220.45 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $467.00 / $467.00 / $467.00
| Professional | 50 | $467.00 | $467.00 | $467.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.35 / $186.16 / $306.30
| Professional | | $122.35 | $186.16 | $306.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.01 / $226.88 / $446.12
| Professional | | $180.01 | $226.88 | $446.12 |