- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.70 / $119.60 / $225.68
| Professional | | $83.70 | $119.60 | $225.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.57 / $188.89 / $578.83
| Professional | | $155.57 | $188.89 | $578.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.76 / $182.08 / $452.50
| Professional | | $116.76 | $182.08 | $452.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.57 / $183.70 / $452.50
| Professional | | $117.57 | $183.70 | $452.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.53 / $185.81 / $540.16
| Professional | | $135.53 | $185.81 | $540.16 |