- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.75 / $189.40 / $251.98
| Professional | | $133.75 | $189.40 | $251.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.38 / $236.53 / $411.80
| Professional | | $149.38 | $236.53 | $411.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.90 / $253.90 / $253.90
| Professional | | $253.90 | $253.90 | $253.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.90 / $192.82 / $271.36
| Professional | | $163.90 | $192.82 | $271.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.77 / $227.83 / $398.35
| Professional | | $162.77 | $227.83 | $398.35 |