- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.09 / $130.09 / $212.58
| Professional | | $130.09 | $130.09 | $212.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.79 / $229.16 / $229.16
| Professional | | $194.79 | $229.16 | $229.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.52 / $195.03 / $284.73
| Professional | | $128.52 | $195.03 | $284.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.90 / $181.52 / $2,654.97
| Professional | | $140.90 | $181.52 | $2,654.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.25 / $169.08 / $257.77
| Professional | | $134.25 | $169.08 | $257.77 |