- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $218.78 / $346.74
| Professional | | $181.97 | $218.78 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $416.87 / $676.08
| Professional | | $281.84 | $416.87 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $416.87 / $602.56 / $1,000.00
| Professional | 50 | $416.87 | $602.56 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $602.56 / $891.25
| Professional | | $389.05 | $602.56 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $501.19 / $758.58
| Professional | | $363.08 | $501.19 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $398.11 / $1,071.52
| Professional | | $229.09 | $398.11 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $380.19 / $758.58
| Professional | | $213.80 | $380.19 | $758.58 |