- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.04 / $131.22 / $286.64
| Professional | | $66.04 | $131.22 | $286.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.82 / $414.71 / $869.25
| Professional | | $351.82 | $414.71 | $869.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.07 / $201.26 / $565.34
| Professional | | $108.07 | $201.26 | $565.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.07 / $234.25 / $565.34
| Professional | | $108.07 | $234.25 | $565.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.07 / $355.08 / $1,032.25
| Professional | | $246.07 | $355.08 | $1,032.25 |