- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.37 / $117.37 / $1,406.11
| Professional | | $117.37 | $117.37 | $1,406.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.00 / $323.00 / $3,316.00
| Professional | | $269.00 | $323.00 | $3,316.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $403.50 / $546.00 / $4,974.00
| Professional | 50 | $403.50 | $546.00 | $4,974.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.71 / $281.33 / $3,645.36
| Professional | | $165.71 | $281.33 | $3,645.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.34 / $4,805.16 / $5,955.85
| Professional | | $2,137.34 | $4,805.16 | $5,955.85 |