- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $691.83 / $2,754.23
| Professional | | $302.00 | $691.83 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $208.93 / $794.33 / $2,630.27
| Professional | 50 | $208.93 | $794.33 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $912.01 / $3,630.78
| Professional | | $794.33 | $912.01 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $676.08 / $1,122.02 / $5,495.41
| Professional | 50 | $676.08 | $1,122.02 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $1,096.48 / $3,467.37
| Professional | | $436.52 | $1,096.48 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $3,090.30
| Facility | | $295.12 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,288.25 / $5,623.41
| Professional | | $489.78 | $1,288.25 | $5,623.41 |