- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.74 / $158.88 / $319.05
| Professional | | $100.74 | $158.88 | $319.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.57 / $207.44 / $283.87
| Professional | | $112.57 | $207.44 | $283.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.35 / $226.19 / $371.67
| Professional | | $159.35 | $226.19 | $371.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.34 / $203.67 / $268.58
| Professional | | $135.34 | $203.67 | $268.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.12 / $265.91 / $464.20
| Professional | | $139.12 | $265.91 | $464.20 |