- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.43 / $234.91 / $454.11
| Professional | | $91.43 | $234.91 | $454.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.55 / $204.82 / $637.03
| Professional | | $121.55 | $204.82 | $637.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.85 / $559.98 / $842.83
| Professional | | $145.85 | $559.98 | $842.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.32 / $305.20 / $804.30
| Professional | | $132.32 | $305.20 | $804.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.43 / $234.91 / $454.11
| Professional | | $91.43 | $234.91 | $454.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.56 / $637.48 / $871.79
| Professional | | $503.56 | $637.48 | $871.79 |