- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.14 / $168.55 / $320.70
| Professional | | $115.14 | $168.55 | $320.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.85 / $199.96 / $340.82
| Professional | | $133.85 | $199.96 | $340.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.25 / $231.20 / $434.65
| Professional | | $138.25 | $231.20 | $434.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.82 / $303.04 / $1,710.56
| Professional | | $207.82 | $303.04 | $1,710.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.57 / $255.38 / $445.46
| Professional | | $196.57 | $255.38 | $445.46 |