- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.43 / $208.82 / $397.76
| Professional | | $151.43 | $208.82 | $397.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.78 / $253.09 / $535.91
| Professional | | $152.78 | $253.09 | $535.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.70 / $404.92 / $460.01
| Professional | | $298.70 | $404.92 | $460.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.30 / $292.66 / $438.98
| Professional | | $179.30 | $292.66 | $438.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.01 / $280.23 / $561.78
| Professional | | $160.01 | $280.23 | $561.78 |