- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.84 / $199.86 / $701.68
| Professional | | $137.84 | $199.86 | $701.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.40 / $273.95 / $609.27
| Professional | | $232.40 | $273.95 | $609.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.11 / $226.46 / $609.27
| Professional | | $164.11 | $226.46 | $609.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.36 / $255.65 / $609.27
| Professional | | $208.36 | $255.65 | $609.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.24 / $229.81 / $747.81
| Professional | | $200.24 | $229.81 | $747.81 |