- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.24 / $215.41 / $1,001.00
| Professional | | $136.24 | $215.41 | $1,001.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,219.44 / $1,342.50 / $1,410.00
| Professional | 50 | $1,219.44 | $1,342.50 | $1,410.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.86 / $227.06 / $745.00
| Professional | | $154.86 | $227.06 | $745.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.72 / $293.10 / $745.00
| Professional | | $196.72 | $293.10 | $745.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.26 / $280.85 / $914.40
| Professional | | $236.26 | $280.85 | $914.40 |