- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.48 / $179.27 / $817.00
| Professional | | $125.48 | $179.27 | $817.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $248.49 / $826.68 / $1,225.50
| Professional | 50 | $248.49 | $826.68 | $1,225.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,016.71 / $1,329.33 / $1,512.81
| Facility | | $1,016.71 | $1,329.33 | $1,512.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.09 / $242.85 / $580.09
| Professional | | $123.09 | $242.85 | $580.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.04 / $242.85 / $580.09
| Professional | | $223.04 | $242.85 | $580.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.63 / $221.33 / $711.99
| Professional | | $209.63 | $221.33 | $711.99 |