- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.53 / $191.58 / $331.84
| Professional | | $131.53 | $191.58 | $331.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.18 / $304.85 / $366.61
| Professional | | $172.18 | $304.85 | $366.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.66 / $241.67 / $452.61
| Professional | | $200.66 | $241.67 | $452.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.67 / $330.95 / $330.95
| Professional | | $226.67 | $330.95 | $330.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.23 / $316.64 / $491.67
| Professional | | $189.23 | $316.64 | $491.67 |