- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.03 / $136.03 / $278.27
| Professional | | $136.03 | $136.03 | $278.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.00 / $780.00 / $1,280.00
| Professional | | $402.00 | $780.00 | $1,280.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $603.00 / $1,170.00 / $1,920.00
| Professional | 50 | $603.00 | $1,170.00 | $1,920.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.63 / $269.26 / $511.59
| Professional | | $183.63 | $269.26 | $511.59 |
- 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
- $300.80 / $530.75 / $848.90
| Professional | | $300.80 | $530.75 | $848.90 |