- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $251.19 / $512.86
| Professional | | $134.90 | $251.19 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $1,174.90
| Professional | | $331.13 | $331.13 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $323.59 / $1,174.90
| Professional | | $169.82 | $323.59 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $371.54 / $776.25
| Professional | | $323.59 | $371.54 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $269.15 / $691.83
| Professional | | $147.91 | $269.15 | $691.83 |