- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.18 / $200.92 / $204.38
| Professional | | $159.18 | $200.92 | $204.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.42 / $318.76 / $636.44
| Professional | | $270.42 | $318.76 | $636.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.82 / $250.74 / $404.09
| Professional | | $191.82 | $250.74 | $404.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.20 / $253.36 / $404.09
| Professional | | $189.20 | $253.36 | $404.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.00 / $253.81 / $737.83
| Professional | | $235.00 | $253.81 | $737.83 |