- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.53 / $162.76 / $226.84
| Professional | | $110.53 | $162.76 | $226.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.56 / $356.93 / $356.93
| Professional | | $348.56 | $356.93 | $356.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.49 / $128.49 / $128.49
| Professional | | $128.49 | $128.49 | $128.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.06 / $291.06 / $291.06
| Professional | | $291.06 | $291.06 | $291.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.55 / $190.79 / $291.06
| Professional | | $133.55 | $190.79 | $291.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.42 / $261.16 / $332.39
| Professional | | $237.42 | $261.16 | $332.39 |