- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.51 / $151.81 / $402.44
| Professional | | $118.51 | $151.81 | $402.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.87 / $306.87 / $306.87
| Professional | | $306.87 | $306.87 | $306.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.56 / $413.70 / $486.46
| Professional | | $359.56 | $413.70 | $486.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.30 / $403.97 / $471.30
| Professional | | $370.30 | $403.97 | $471.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.12 / $379.70 / $487.20
| Professional | | $194.12 | $379.70 | $487.20 |