- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.14 / $111.78 / $217.96
| Professional | | $94.14 | $111.78 | $217.96 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $150.62 / $170.12 / $931.50
| Professional | 50 | $150.62 | $170.12 | $931.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.03 / $184.03 / $209.79
| Professional | | $184.03 | $184.03 | $209.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.03 / $184.03 / $184.03
| Facility | | $184.03 | $184.03 | $184.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.90 / $129.46 / $210.10
| Professional | | $106.90 | $129.46 | $210.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.69 / $106.03 / $184.03
| Facility | | $55.69 | $106.03 | $184.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.47 / $164.03 / $217.56
| Professional | | $118.47 | $164.03 | $217.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $200.00
| Facility | | $200.00 | $200.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.12 / $207.20 / $247.90
| Professional | | $182.12 | $207.20 | $247.90 |