- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $154.88 / $275.42
| Professional | | $114.82 | $154.88 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $154.88 / $154.88
| Professional | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $190.55 / $363.08
| Professional | | $134.90 | $190.55 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $204.17 / $295.12
| Professional | | $154.88 | $204.17 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $177.83 / $346.74
| Professional | | $144.54 | $177.83 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $158.49 / $245.47
| Professional | | $107.15 | $158.49 | $245.47 |