- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.37 / $212.06 / $581.52
| Professional | | $109.37 | $212.06 | $581.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.97 / $241.63 / $387.36
| Professional | | $136.97 | $241.63 | $387.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.22 / $179.97 / $222.49
| Professional | | $140.22 | $179.97 | $222.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.04 / $258.30 / $435.84
| Professional | | $160.04 | $258.30 | $435.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.18 / $242.76 / $415.36
| Professional | | $179.18 | $242.76 | $415.36 |