- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.59 / $132.66 / $203.60
| Professional | | $104.59 | $132.66 | $203.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.55 / $631.55 / $631.55
| Professional | | $631.55 | $631.55 | $631.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.83 / $211.17 / $382.67
| Professional | | $138.83 | $211.17 | $382.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.83 / $220.57 / $322.19
| Professional | | $148.83 | $220.57 | $322.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.94 / $240.35 / $698.72
| Professional | | $224.94 | $240.35 | $698.72 |