- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $478.63 / $1,148.15
| Professional | | $190.55 | $478.63 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $758.58 / $1,548.82
| Professional | | $389.05 | $758.58 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $588.84 / $1,148.15 / $2,290.87
| Professional | 50 | $588.84 | $1,148.15 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $501.19 / $1,148.15
| Professional | | $208.93 | $501.19 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,630.27 / $10,471.29
| Facility | | $1,659.59 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $676.08 / $1,548.82
| Professional | | $316.23 | $676.08 | $1,548.82 |