- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.87 / $143.22 / $215.89
| Professional | | $116.87 | $143.22 | $215.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.45 / $144.85 / $254.57
| Professional | | $88.45 | $144.85 | $254.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.52 / $210.62 / $263.27
| Professional | | $175.52 | $210.62 | $263.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.02 / $166.12 / $292.85
| Professional | | $124.02 | $166.12 | $292.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.13 / $188.53 / $285.08
| Professional | | $134.13 | $188.53 | $285.08 |