- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $177.83 / $457.09
| Professional | | $147.91 | $177.83 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $323.59 / $562.34
| Professional | | $208.93 | $323.59 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $251.19 / $478.63
| Professional | | $54.95 | $251.19 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $263.03 / $489.78
| Professional | | $186.21 | $263.03 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,513.56
| Professional | | $1,318.26 | $1,318.26 | $1,513.56 |