- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.20 / $149.63 / $663.24
| Professional | | $103.20 | $149.63 | $663.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.53 / $194.53 / $238.31
| Professional | | $194.53 | $194.53 | $238.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.08 / $225.56 / $709.87
| Professional | | $157.08 | $225.56 | $709.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.75 / $225.56 / $709.87
| Professional | | $178.75 | $225.56 | $709.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.13 / $233.06 / $871.29
| Professional | | $168.13 | $233.06 | $871.29 |