- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.80 / $163.80 / $309.94
| Professional | | $130.80 | $163.80 | $309.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.77 / $222.58 / $253.18
| Professional | | $180.77 | $222.58 | $253.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.36 / $192.74 / $325.39
| Professional | | $140.36 | $192.74 | $325.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.13 / $198.90 / $1,377.92
| Professional | | $148.13 | $198.90 | $1,377.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.19 / $178.50 / $345.30
| Professional | | $142.19 | $178.50 | $345.30 |