- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.03 / $246.81 / $832.86
| Professional | | $138.03 | $246.81 | $832.86 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $342.56 / $342.56 / $342.56
| Professional | 50 | $342.56 | $342.56 | $342.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.35 / $476.65 / $1,031.11
| Professional | | $404.35 | $476.65 | $1,031.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.19 / $294.63 / $483.97
| Professional | | $218.19 | $294.63 | $483.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $294.63 / $483.97
| Professional | | $150.00 | $294.63 | $483.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.37 / $398.57 / $616.05
| Professional | | $332.37 | $398.57 | $616.05 |