- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $190.55 / $426.58
| Professional | | $107.15 | $190.55 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $263.03 / $263.03 / $263.03
| Professional | 50 | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Facility | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $177.83 / $302.00
| Professional | | $112.20 | $177.83 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $302.00 / $346.74
| Facility | | $177.83 | $302.00 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $302.00 / $346.74
| Professional | | $177.83 | $302.00 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $181.97 / $302.00
| Facility | | $134.90 | $181.97 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $177.83 / $363.08
| Professional | | $79.43 | $177.83 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $245.47 / $407.38
| Professional | | $162.18 | $245.47 | $407.38 |