- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.19 / $110.19 / $121.96
| Professional | | $110.19 | $110.19 | $121.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.00 / $521.00 / $576.00
| Professional | | $322.00 | $521.00 | $576.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $483.00 / $781.50 / $864.00
| Professional | 50 | $483.00 | $781.50 | $864.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.63 / $158.12 / $231.10
| Professional | | $121.63 | $158.12 | $231.10 |
- 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
- $123.17 / $237.53 / $387.40
| Professional | | $123.17 | $237.53 | $387.40 |