- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.44 / $320.85 / $1,344.55
| Professional | | $176.44 | $320.85 | $1,344.55 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,243.51 / $1,243.51 / $1,243.51
| Professional | 50 | $1,243.51 | $1,243.51 | $1,243.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.31 / $358.57 / $936.38
| Professional | | $195.31 | $358.57 | $936.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.48 / $382.57 / $936.38
| Professional | | $236.48 | $382.57 | $936.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.67 / $408.56 / $1,149.30
| Professional | | $339.67 | $408.56 | $1,149.30 |