- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.27 / $139.02 / $190.98
| Professional | | $81.27 | $139.02 | $190.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.13 / $196.84 / $603.21
| Professional | | $162.13 | $196.84 | $603.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.48 / $170.72 / $390.31
| Professional | | $99.48 | $170.72 | $390.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.48 / $179.80 / $390.31
| Professional | | $101.48 | $179.80 | $390.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.12 / $175.63 / $517.28
| Professional | | $129.12 | $175.63 | $517.28 |