- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.05 / $164.47 / $250.86
| Professional | | $130.05 | $164.47 | $250.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.53 / $186.36 / $320.75
| Professional | | $137.53 | $186.36 | $320.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.44 / $217.97 / $332.84
| Professional | | $149.44 | $217.97 | $332.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.76 / $1,419.28 / $1,671.68
| Professional | | $1,063.76 | $1,419.28 | $1,671.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.97 / $221.95 / $362.40
| Professional | | $147.97 | $221.95 | $362.40 |