- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.44 / $227.98 / $395.51
| Professional | | $143.44 | $227.98 | $395.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.45 / $129.76 / $232.72
| Professional | | $59.45 | $129.76 | $232.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.11 / $266.24 / $493.94
| Professional | | $109.11 | $266.24 | $493.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.36 / $227.48 / $236.23
| Professional | | $193.36 | $227.48 | $236.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.84 / $231.79 / $418.00
| Professional | | $173.84 | $231.79 | $418.00 |