- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.05 / $533.98 / $1,503.61
| Professional | | $161.05 | $533.98 | $1,503.61 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $193.26 / $885.31 / $2,812.50
| Professional | 50 | $193.26 | $885.31 | $2,812.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,395.61 / $2,892.86 / $2,975.47
| Facility | | $2,395.61 | $2,892.86 | $2,975.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.17 / $445.17 / $1,085.49
| Professional | | $445.17 | $445.17 | $1,085.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.20 / $412.25 / $1,085.49
| Professional | | $227.20 | $412.25 | $1,085.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.25 / $447.15 / $1,085.49
| Professional | | $266.25 | $447.15 | $1,085.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.79 / $542.58 / $1,332.32
| Professional | | $359.79 | $542.58 | $1,332.32 |