- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.02 / $255.18 / $701.68
| Professional | | $134.02 | $255.18 | $701.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.24 / $289.24 / $964.83
| Professional | | $289.24 | $289.24 | $964.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.35 / $337.65 / $964.83
| Professional | | $184.35 | $337.65 | $964.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.22 / $357.78 / $964.83
| Professional | | $211.22 | $357.78 | $964.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.87 / $369.14 / $1,184.22
| Professional | | $256.87 | $369.14 | $1,184.22 |