- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $204.17 / $575.44
| Professional | | $151.36 | $204.17 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $354.81 / $501.19
| Professional | | $165.96 | $354.81 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $251.19 / $524.81 / $741.31
| Professional | 50 | $251.19 | $524.81 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $389.05 / $562.34
| Professional | | $223.87 | $389.05 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $309.03 / $524.81
| Professional | | $190.55 | $309.03 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $331.13 / $645.65
| Professional | | $204.17 | $331.13 | $645.65 |