- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $467.74 / $1,230.27
| Professional | | $91.20 | $467.74 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $138.04 / $316.23 / $707.95
| Professional | 50 | $138.04 | $316.23 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $288.40 / $1,445.44
| Professional | | $190.55 | $288.40 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $288.40 / $426.58 / $2,137.96
| Professional | 50 | $288.40 | $426.58 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $239.88 / $1,000.00
| Professional | | $138.04 | $239.88 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,737.80 / $3,235.94
| Facility | | $794.33 | $1,737.80 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $616.60 / $1,737.80
| Professional | | $162.18 | $616.60 | $1,737.80 |