- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.20 / $138.63 / $209.64
| Professional | | $114.20 | $138.63 | $209.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.85 / $159.54 / $246.57
| Professional | | $124.85 | $159.54 | $246.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.59 / $190.77 / $305.55
| Professional | | $136.59 | $190.77 | $305.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.90 / $232.93 / $1,150.72
| Professional | | $149.90 | $232.93 | $1,150.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.24 / $188.73 / $314.13
| Professional | | $143.24 | $188.73 | $314.13 |