- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.19 / $738.99 / $3,546.71
| Professional | | $576.19 | $738.99 | $3,546.71 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $288.10 / $288.10 / $4,938.00
| Professional | 50 | $288.10 | $288.10 | $4,938.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.41 / $1,203.41 / $3,000.30
| Professional | | $1,203.41 | $1,203.41 | $3,000.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.27 / $1,164.13 / $3,000.30
| Professional | | $556.27 | $1,164.13 | $3,000.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.75 / $1,362.89 / $3,000.30
| Professional | | $923.75 | $1,362.89 | $3,000.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.49 / $1,174.81 / $3,682.53
| Professional | | $1,064.49 | $1,174.81 | $3,682.53 |