- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.75 / $126.75 / $163.43
| Professional | | $126.75 | $126.75 | $163.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $374.00 / $605.00 / $765.00
| Professional | | $374.00 | $605.00 | $765.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $561.00 / $907.50 / $1,147.50
| Professional | 50 | $561.00 | $907.50 | $1,147.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.50 / $278.82 / $464.86
| Professional | | $217.50 | $278.82 | $464.86 |
- 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
- $270.58 / $314.13 / $769.61
| Professional | | $270.58 | $314.13 | $769.61 |