- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.49 / $223.46 / $3,799.61
| Professional | | $155.49 | $223.46 | $3,799.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.72 / $280.69 / $2,675.15
| Professional | | $172.72 | $280.69 | $2,675.15 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $259.08 / $418.05 / $4,012.73
| Professional | 50 | $259.08 | $418.05 | $4,012.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.09 / $307.62 / $3,850.06
| Professional | | $177.09 | $307.62 | $3,850.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.07 / $410.72 / $2,990.13
| Professional | | $178.07 | $410.72 | $2,990.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.78 / $223.46 / $3,799.61
| Professional | | $153.78 | $223.46 | $3,799.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.00 / $2,799.06 / $3,857.80
| Professional | | $1,487.00 | $2,799.06 | $3,857.80 |