- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.71 / $114.18 / $148.25
| Professional | | $62.71 | $114.18 | $148.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.38 / $183.79 / $514.01
| Professional | | $151.38 | $183.79 | $514.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.83 / $147.46 / $400.88
| Professional | | $63.83 | $147.46 | $400.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.52 / $168.22 / $400.88
| Professional | | $85.52 | $168.22 | $400.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.16 / $200.42 / $582.65
| Professional | | $134.16 | $200.42 | $582.65 |