- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.38 / $235.87 / $468.92
| Professional | | $119.38 | $235.87 | $468.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.87 / $286.68 / $528.89
| Professional | | $134.87 | $286.68 | $528.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.33 / $272.37 / $556.23
| Professional | | $159.33 | $272.37 | $556.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.57 / $367.27 / $509.05
| Professional | | $275.57 | $367.27 | $509.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.99 / $339.93 / $936.31
| Professional | | $195.99 | $339.93 | $936.31 |