- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.95 / $175.96 / $796.70
| Professional | | $116.95 | $175.96 | $796.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.30 / $179.30 / $266.05
| Professional | | $179.30 | $179.30 | $266.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.38 / $191.48 / $266.05
| Professional | | $153.38 | $191.48 | $266.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.72 / $179.55 / $273.37
| Professional | | $116.72 | $179.55 | $273.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.51 / $251.14 / $467.12
| Professional | | $203.51 | $251.14 | $467.12 |