- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.63 / $157.94 / $242.37
| Professional | | $110.63 | $157.94 | $242.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.26 / $364.77 / $554.88
| Professional | | $210.26 | $364.77 | $554.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.16 / $383.43 / $664.70
| Professional | | $232.16 | $383.43 | $664.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.58 / $359.94 / $606.10
| Professional | | $227.58 | $359.94 | $606.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.66 / $319.38 / $832.40
| Professional | | $175.66 | $319.38 | $832.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.14 / $293.35 / $591.45
| Professional | | $170.14 | $293.35 | $591.45 |