- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.80 / $137.86 / $208.19
| Professional | | $91.80 | $137.86 | $208.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.14 / $156.05 / $275.83
| Professional | | $99.14 | $156.05 | $275.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.27 / $162.71 / $283.41
| Professional | | $107.27 | $162.71 | $283.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.92 / $1,087.92 / $1,275.53
| Professional | | $753.92 | $1,087.92 | $1,275.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.36 / $197.89 / $321.50
| Professional | | $139.36 | $197.89 | $321.50 |