- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $2,777.50 / $2,777.50 / $2,777.50
| Facility | 50 | $2,777.50 | $2,777.50 | $2,777.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.68 / $205.83 / $356.86
| Professional | | $147.68 | $205.83 | $356.86 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $249.42 / $249.42 / $249.42
| Professional | 50 | $249.42 | $249.42 | $249.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.60 / $384.99 / $807.84
| Professional | | $326.60 | $384.99 | $807.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.47 / $256.99 / $380.99
| Professional | | $196.47 | $256.99 | $380.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.27 / $256.99 / $367.72
| Professional | | $133.27 | $256.99 | $367.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.84 / $277.75 / $888.46
| Professional | | $238.84 | $277.75 | $888.46 |