- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.72 / $348.51 / $1,321.34
| Professional | | $191.72 | $348.51 | $1,321.34 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,890.48 / $1,890.48 / $1,890.48
| Professional | 50 | $1,890.48 | $1,890.48 | $1,890.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,515.45 / $3,515.45 / $4,502.25
| Facility | | $3,515.45 | $3,515.45 | $4,502.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.33 / $912.33 / $912.33
| Professional | | $912.33 | $912.33 | $912.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.58 / $357.74 / $912.33
| Professional | | $190.58 | $357.74 | $912.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.50 / $382.34 / $912.33
| Professional | | $247.50 | $382.34 | $912.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.18 / $430.82 / $1,119.78
| Professional | | $334.18 | $430.82 | $1,119.78 |