- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.30 / $320.14 / $1,265.92
| Professional | | $235.30 | $320.14 | $1,265.92 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,232.86 / $1,232.86 / $1,849.31
| Professional | 50 | $1,232.86 | $1,232.86 | $1,849.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,930.00 / $1,930.00 / $2,397.13
| Facility | | $1,930.00 | $1,930.00 | $2,397.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.22 / $376.58 / $1,605.85
| Professional | | $327.22 | $376.58 | $1,605.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.69 / $610.36 / $1,605.85
| Professional | | $360.69 | $610.36 | $1,605.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.84 / $596.44 / $1,971.00
| Professional | | $369.84 | $596.44 | $1,971.00 |