- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.76 / $210.89 / $313.33
| Professional | | $109.76 | $210.89 | $313.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.60 / $168.88 / $233.36
| Professional | | $140.60 | $168.88 | $233.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.59 / $262.01 / $516.50
| Professional | | $150.59 | $262.01 | $516.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.93 / $292.91 / $507.33
| Professional | | $152.93 | $292.91 | $507.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.29 / $230.76 / $318.45
| Professional | | $132.29 | $230.76 | $318.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.13 / $349.66 / $542.55
| Professional | | $234.13 | $349.66 | $542.55 |