- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $562.34 / $1,819.70
| Professional | | $323.59 | $562.34 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,754.23
| Professional | 50 | $2,691.53 | $2,691.53 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,698.24
| Facility | | $1,584.89 | $1,584.89 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $602.56 / $870.96
| Professional | | $588.84 | $602.56 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $691.83 / $870.96
| Professional | | $218.78 | $691.83 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $870.96
| Professional | | $407.38 | $407.38 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $630.96 / $1,258.93
| Professional | | $512.86 | $630.96 | $1,258.93 |