- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $128.82 / $208.93
| Professional | | $93.33 | $128.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $208.93 / $302.00
| Professional | | $151.36 | $208.93 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $288.40 / $446.68
| Professional | | $190.55 | $288.40 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $302.00 / $467.74
| Professional | | $177.83 | $302.00 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $177.83 / $467.74
| Professional | | $158.49 | $177.83 | $467.74 |