- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.62 / $168.69 / $288.14
| Professional | | $105.62 | $168.69 | $288.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.97 / $201.81 / $610.33
| Professional | | $168.97 | $201.81 | $610.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.60 / $181.36 / $483.53
| Professional | | $114.60 | $181.36 | $483.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.83 / $239.44 / $483.53
| Professional | | $152.83 | $239.44 | $483.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.18 / $233.41 / $678.53
| Professional | | $169.18 | $233.41 | $678.53 |