- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $134.90 / $331.13
| Professional | | $75.86 | $134.90 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $208.93 / $208.93 / $208.93
| Professional | 50 | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $120.23 / $204.17
| Professional | | $100.00 | $120.23 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $229.09 / $245.47
| Facility | | $131.83 | $229.09 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $229.09 / $245.47
| Professional | | $131.83 | $229.09 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.13 / $128.82 / $229.09
| Facility | | $74.13 | $128.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $147.91 / $275.42
| Professional | | $79.43 | $147.91 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $165.96 / $245.47
| Professional | | $114.82 | $165.96 | $245.47 |