- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.15 / $148.15 / $157.13
| Professional | | $148.15 | $148.15 | $157.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.00 / $707.00 / $748.00
| Professional | | $437.00 | $707.00 | $748.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $655.50 / $1,060.50 / $1,122.00
| Professional | 50 | $655.50 | $1,060.50 | $1,122.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.49 / $208.55 / $303.02
| Professional | | $159.49 | $208.55 | $303.02 |
- 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
- $162.47 / $310.64 / $505.71
| Professional | | $162.47 | $310.64 | $505.71 |