- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.60 / $188.88 / $626.48
| Professional | | $107.60 | $188.88 | $626.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.49 / $311.92 / $923.18
| Professional | | $253.49 | $311.92 | $923.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.22 / $271.94 / $923.18
| Professional | | $163.22 | $271.94 | $923.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.06 / $289.02 / $923.18
| Professional | | $167.06 | $289.02 | $923.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.50 / $326.39 / $1,133.09
| Professional | | $206.50 | $326.39 | $1,133.09 |