- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.17 / $117.17 / $283.27
| Professional | | $117.17 | $117.17 | $283.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.00 / $668.00 / $1,283.00
| Professional | | $345.00 | $668.00 | $1,283.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $517.50 / $1,002.00 / $1,924.50
| Professional | 50 | $517.50 | $1,002.00 | $1,924.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.78 / $227.66 / $461.63
| Professional | | $151.78 | $227.66 | $461.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.58 / $485.66 / $929.26
| Professional | | $277.58 | $485.66 | $929.26 |