- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $131.83 / $218.78
| Professional | | $91.20 | $131.83 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $269.15 / $354.81
| Professional | | $204.17 | $269.15 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $269.15 / $407.38
| Professional | | $154.88 | $269.15 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $269.15 / $323.59
| Professional | | $134.90 | $269.15 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $194.98 / $316.23
| Professional | | $102.33 | $194.98 | $316.23 |