- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.15 / $189.68 / $316.83
| Professional | | $124.15 | $189.68 | $316.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.46 / $253.10 / $760.39
| Professional | | $208.46 | $253.10 | $760.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.09 / $213.52 / $574.75
| Professional | | $132.09 | $213.52 | $574.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.75 / $272.32 / $574.75
| Professional | | $164.75 | $272.32 | $574.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.40 / $237.08 / $815.53
| Professional | | $210.40 | $237.08 | $815.53 |