- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.04 / $131.51 / $336.90
| Professional | | $64.04 | $131.51 | $336.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.71 / $249.71 / $623.75
| Professional | | $249.71 | $249.71 | $623.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.37 / $192.00 / $623.75
| Professional | | $89.37 | $192.00 | $623.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.41 / $200.93 / $623.75
| Professional | | $104.41 | $200.93 | $623.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.69 / $210.78 / $765.59
| Professional | | $155.69 | $210.78 | $765.59 |