- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $281.84 / $588.84
| Professional | | $158.49 | $281.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $512.86 / $691.83
| Professional | | $346.74 | $512.86 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $288.40 / $524.81 / $1,023.29
| Professional | 50 | $288.40 | $524.81 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $346.74 / $524.81
| Professional | | $218.78 | $346.74 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,479.11 / $5,370.32
| Facility | | $1,288.25 | $1,479.11 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $457.09 / $933.25
| Professional | | $269.15 | $457.09 | $933.25 |