- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.79 / $110.79 / $190.04
| Professional | | $110.79 | $110.79 | $190.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.00 / $296.00 / $496.00
| Professional | | $203.00 | $296.00 | $496.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $304.50 / $510.00 / $744.00
| Professional | 50 | $304.50 | $510.00 | $744.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.80 / $214.55 / $421.39
| Professional | | $130.80 | $214.55 | $421.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.50 / $435.76 / $712.79
| Professional | | $247.50 | $435.76 | $712.79 |