- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.58 / $183.71 / $375.46
| Professional | | $118.58 | $183.71 | $375.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.46 / $242.35 / $347.98
| Professional | | $159.46 | $242.35 | $347.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.19 / $284.41 / $455.80
| Professional | | $165.19 | $284.41 | $455.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.67 / $285.18 / $475.38
| Professional | | $184.67 | $285.18 | $475.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.58 / $194.52 / $390.81
| Professional | | $118.58 | $194.52 | $390.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.89 / $312.72 / $501.16
| Professional | | $203.89 | $312.72 | $501.16 |