- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $151.36 / $323.59
| Professional | | $112.20 | $151.36 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $724.44 / $758.58
| Professional | | $446.68 | $724.44 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $371.54 / $676.08 / $1,148.15
| Professional | 50 | $371.54 | $676.08 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $281.84 / $467.74
| Professional | | $218.78 | $281.84 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $295.12 / $3,090.30
| Facility | | $257.04 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $281.84 / $741.31
| Professional | | $213.80 | $281.84 | $741.31 |