- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $141.25 / $218.78
| Professional | | $114.82 | $141.25 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $257.04 / $416.87
| Professional | | $173.78 | $257.04 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $363.08 / $549.54
| Professional | | $239.88 | $363.08 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $309.03 / $467.74
| Professional | | $229.09 | $309.03 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $229.09 / $489.78
| Professional | | $138.04 | $229.09 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $239.88 / $478.63
| Professional | | $141.25 | $239.88 | $478.63 |