- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.65 / $202.65 / $297.01
| Professional | | $113.65 | $202.65 | $297.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.49 / $249.38 / $461.44
| Professional | | $132.49 | $249.38 | $461.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.82 / $191.72 / $337.23
| Professional | | $178.82 | $191.72 | $337.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.50 / $290.41 / $391.06
| Professional | | $193.50 | $290.41 | $391.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.51 / $294.70 / $534.40
| Professional | | $205.51 | $294.70 | $534.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.66 / $206.81 / $206.81
| Professional | | $103.66 | $206.81 | $206.81 |