- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.93 / $323.30 / $1,504.81
| Professional | | $249.93 | $323.30 | $1,504.81 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $2,257.21 / $2,257.21 / $2,257.21
| Professional | 50 | $2,257.21 | $2,257.21 | $2,257.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.30 / $435.62 / $1,398.15
| Professional | | $292.30 | $435.62 | $1,398.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.19 / $570.38 / $1,398.15
| Professional | | $403.19 | $570.38 | $1,398.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.58 / $532.34 / $1,716.08
| Professional | | $493.58 | $532.34 | $1,716.08 |