- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.65 / $152.65 / $1,553.85
| Professional | | $152.65 | $152.65 | $1,553.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.00 / $410.00 / $3,502.00
| Professional | | $342.00 | $410.00 | $3,502.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $513.00 / $694.50 / $5,253.00
| Professional | 50 | $513.00 | $694.50 | $5,253.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.62 / $357.72 / $3,808.96
| Professional | | $210.62 | $357.72 | $3,808.96 |
- 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
- $2,592.69 / $5,330.98 / $6,222.47
| Professional | | $2,592.69 | $5,330.98 | $6,222.47 |