- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $151.36 / $436.52
| Professional | | $117.49 | $151.36 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $199.53 / $363.08
| Professional | | $151.36 | $199.53 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $169.82 / $288.40
| Professional | | $120.23 | $169.82 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $199.53 / $1,148.15
| Professional | | $131.83 | $199.53 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $147.91 / $257.04
| Professional | | $117.49 | $147.91 | $257.04 |