- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.53 / $454.93 / $4,758.24
| Professional | | $200.53 | $454.93 | $4,758.24 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $909.86 / $934.25 / $1,401.37
| Professional | 50 | $909.86 | $934.25 | $1,401.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.90 / $1,359.00 / $6,363.01
| Professional | | $250.90 | $1,359.00 | $6,363.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.60 / $2,448.17 / $6,363.01
| Professional | | $267.60 | $2,448.17 | $6,363.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,607.91 / $5,750.74 / $7,809.89
| Professional | | $2,607.91 | $5,750.74 | $7,809.89 |