- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $1,318.26 / $3,235.94
| Professional | | $120.23 | $1,318.26 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $363.08 / $3,311.31
| Professional | | $269.15 | $363.08 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $407.38 / $549.54 / $5,011.87
| Professional | 50 | $407.38 | $549.54 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $281.84 / $3,630.78
| Professional | | $165.96 | $281.84 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $5,370.32
| Facility | | $1,288.25 | $1,584.89 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $457.09 / $5,011.87
| Professional | | $190.55 | $457.09 | $5,011.87 |