- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.86 / $204.94 / $320.54
| Professional | | $124.86 | $204.94 | $320.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.25 / $250.29 / $729.61
| Professional | | $204.25 | $250.29 | $729.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.02 / $214.08 / $577.66
| Professional | | $133.02 | $214.08 | $577.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.13 / $275.20 / $577.66
| Professional | | $166.13 | $275.20 | $577.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.39 / $281.85 / $819.35
| Professional | | $211.39 | $281.85 | $819.35 |