- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.07 / $220.37 / $303.97
| Professional | | $118.07 | $220.37 | $303.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.69 / $408.68 / $880.65
| Professional | | $346.69 | $408.68 | $880.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.34 / $303.70 / $581.01
| Professional | | $177.34 | $303.70 | $581.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.37 / $346.59 / $581.01
| Professional | | $186.37 | $346.59 | $581.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.04 / $364.92 / $1,060.85
| Professional | | $283.04 | $364.92 | $1,060.85 |