- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $147.91 / $199.53
| Professional | | $114.82 | $147.91 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $102.33
| Professional | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Professional | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $173.78 / $281.84
| Professional | | $123.03 | $173.78 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $177.83 / $891.25
| Professional | | $141.25 | $177.83 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $162.18 / $223.87
| Professional | | $134.90 | $162.18 | $223.87 |