- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $204.17 / $537.03
| Professional | | $79.43 | $204.17 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Facility | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $316.23 / $724.44
| Professional | | $162.18 | $316.23 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $245.47 / $478.63 / $1,071.52
| Professional | 50 | $245.47 | $478.63 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $263.03 / $489.78
| Professional | | $112.20 | $263.03 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $794.33 / $3,235.94
| Facility | | $588.84 | $794.33 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $269.15 / $660.69
| Professional | | $112.20 | $269.15 | $660.69 |