- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.87 / $246.57 / $905.62
| Professional | | $153.87 | $246.57 | $905.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.84 / $344.73 / $757.49
| Professional | | $196.84 | $344.73 | $757.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.33 / $600.60 / $1,076.11
| Professional | | $207.33 | $600.60 | $1,076.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.26 / $348.25 / $742.16
| Professional | | $176.26 | $348.25 | $742.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.87 / $246.57 / $905.62
| Professional | | $153.87 | $246.57 | $905.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.39 / $986.67 / $1,190.81
| Professional | | $762.39 | $986.67 | $1,190.81 |