- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.81 / $232.66 / $457.96
| Professional | | $99.81 | $232.66 | $457.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.81 / $453.60 / $974.11
| Professional | | $384.81 | $453.60 | $974.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.52 / $274.88 / $974.11
| Professional | | $130.52 | $274.88 | $974.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.61 / $361.05 / $974.11
| Professional | | $144.61 | $361.05 | $974.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.29 / $345.81 / $1,195.60
| Professional | | $280.29 | $345.81 | $1,195.60 |