- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.82 / $256.43 / $392.45
| Professional | | $138.82 | $256.43 | $392.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.84 / $306.27 / $503.57
| Professional | | $171.84 | $306.27 | $503.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.32 / $229.13 / $297.65
| Professional | | $184.32 | $229.13 | $297.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.30 / $296.02 / $476.68
| Professional | | $196.30 | $296.02 | $476.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.85 / $357.60 / $536.41
| Professional | | $245.85 | $357.60 | $536.41 |