- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $457.09 / $724.44
| Professional | | $213.80 | $457.09 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $676.08 / $1,096.48 / $1,659.59
| Professional | 50 | $676.08 | $1,096.48 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,096.48 / $1,148.15
| Professional | | $676.08 | $1,096.48 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $630.96 / $1,071.52 / $1,737.80
| Professional | 50 | $630.96 | $1,071.52 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $707.95 / $1,023.29
| Professional | | $537.03 | $707.95 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $794.33 / $3,235.94
| Facility | | $467.74 | $794.33 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $891.25 / $1,698.24
| Professional | | $467.74 | $891.25 | $1,698.24 |