- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.13 / $196.13 / $493.74
| Professional | | $196.13 | $196.13 | $493.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.00 / $757.00 / $1,533.00
| Professional | | $392.00 | $757.00 | $1,533.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $588.00 / $1,135.50 / $2,299.50
| Professional | 50 | $588.00 | $1,135.50 | $2,299.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.08 / $505.10 / $1,143.08
| Professional | | $263.08 | $505.10 | $1,143.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.81 / $876.69 / $1,838.19
| Professional | | $669.81 | $876.69 | $1,838.19 |