- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.76 / $221.24 / $544.19
| Professional | | $109.76 | $221.24 | $544.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.54 / $162.79 / $244.19
| Professional | | $101.54 | $162.79 | $244.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.36 / $223.36 / $404.37
| Professional | | $115.36 | $223.36 | $404.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.72 / $315.44 / $1,966.88
| Professional | | $206.72 | $315.44 | $1,966.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.13 / $265.66 / $568.33
| Professional | | $202.13 | $265.66 | $568.33 |