- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.84 / $125.14 / $471.91
| Professional | | $76.84 | $125.14 | $471.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.66 / $197.66 / $943.97
| Professional | | $197.66 | $197.66 | $943.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.17 / $207.51 / $943.97
| Professional | | $124.17 | $207.51 | $943.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.88 / $212.36 / $943.97
| Professional | | $138.88 | $212.36 | $943.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $201.76 / $1,158.61
| Professional | | $141.60 | $201.76 | $1,158.61 |