- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.47 / $198.40 / $411.65
| Professional | | $112.47 | $198.40 | $411.65 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $188.40 / $943.50 / $1,054.50
| Professional | 50 | $188.40 | $943.50 | $1,054.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.85 / $237.53 / $566.01
| Professional | | $121.85 | $237.53 | $566.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.49 / $237.53 / $566.01
| Professional | | $222.49 | $237.53 | $566.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.91 / $221.62 / $694.71
| Professional | | $209.91 | $221.62 | $694.71 |