- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.86 / $211.96 / $992.75
| Professional | | $137.86 | $211.96 | $992.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.60 / $289.52 / $601.86
| Professional | | $245.60 | $289.52 | $601.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.06 / $266.39 / $726.08
| Professional | | $151.06 | $266.39 | $726.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.06 / $279.54 / $726.08
| Professional | | $180.06 | $279.54 | $726.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.36 / $292.66 / $891.18
| Professional | | $257.36 | $292.66 | $891.18 |