- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.27 / $263.27 / $428.01
| Professional | | $263.27 | $263.27 | $428.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.00 / $844.00 / $1,341.00
| Professional | | $506.00 | $844.00 | $1,341.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $633.00 / $1,266.00 / $2,011.50
| Professional | 50 | $633.00 | $1,266.00 | $2,011.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.95 / $505.31 / $909.20
| Professional | | $310.95 | $505.31 | $909.20 |
- 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
- $545.04 / $1,227.78 / $1,581.36
| Professional | | $545.04 | $1,227.78 | $1,581.36 |