- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.88 / $274.88 / $1,047.64
| Professional | | $274.88 | $274.88 | $1,047.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.00 / $1,073.00 / $3,177.00
| Professional | | $827.00 | $1,073.00 | $3,177.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,240.50 / $1,488.00 / $4,765.50
| Professional | 50 | $1,240.50 | $1,488.00 | $4,765.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.54 / $659.00 / $2,757.68
| Professional | | $390.54 | $659.00 | $2,757.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,964.28 / $3,385.42 / $5,619.24
| Professional | | $1,964.28 | $3,385.42 | $5,619.24 |