- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.32 / $242.40 / $618.91
| Professional | | $136.32 | $242.40 | $618.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.85 / $307.49 / $886.48
| Professional | | $260.85 | $307.49 | $886.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.25 / $301.52 / $886.48
| Professional | | $155.25 | $301.52 | $886.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.95 / $329.27 / $886.48
| Professional | | $172.95 | $329.27 | $886.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.73 / $312.87 / $1,088.06
| Professional | | $242.73 | $312.87 | $1,088.06 |