- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.60 / $166.62 / $585.54
| Professional | | $99.60 | $166.62 | $585.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.21 / $266.64 / $781.84
| Professional | | $226.21 | $266.64 | $781.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.04 / $253.00 / $781.84
| Professional | | $152.04 | $253.00 | $781.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.02 / $267.70 / $781.84
| Professional | | $177.02 | $267.70 | $781.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.99 / $281.06 / $959.63
| Professional | | $196.99 | $281.06 | $959.63 |