- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.88 / $681.65 / $1,195.54
| Professional | | $488.88 | $681.65 | $1,195.54 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $733.32 / $835.47 / $4,506.14
| Professional | 50 | $733.32 | $835.47 | $4,506.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.85 / $1,142.06 / $2,690.86
| Professional | | $968.85 | $1,142.06 | $2,690.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.92 / $1,006.94 / $1,291.88
| Professional | | $602.92 | $1,006.94 | $1,291.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.92 / $996.54 / $1,291.88
| Professional | | $602.92 | $996.54 | $1,291.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.10 / $1,048.67 / $3,048.56
| Professional | | $860.10 | $1,048.67 | $3,048.56 |