- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $151.36 / $436.52
| Professional | | $97.72 | $151.36 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $190.55 / $467.74
| Professional | | $162.18 | $190.55 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $173.78 / $229.09
| Professional | | $114.82 | $173.78 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $213.80 / $467.74
| Professional | | $213.80 | $213.80 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $147.91 / $426.58
| Professional | | $114.82 | $147.91 | $426.58 |