- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.34 / $192.34 / $296.11
| Professional | | $192.34 | $192.34 | $296.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.00 / $403.00 / $742.00
| Professional | | $202.00 | $403.00 | $742.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $303.00 / $604.50 / $1,113.00
| Professional | 50 | $303.00 | $604.50 | $1,113.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.35 / $293.52 / $944.66
| Professional | | $172.35 | $293.52 | $944.66 |
- 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
- $375.10 / $655.02 / $2,553.17
| Professional | | $375.10 | $655.02 | $2,553.17 |