- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.29 / $118.44 / $226.54
| Professional | | $36.29 | $118.44 | $226.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.57 / $118.57 / $287.60
| Professional | | $41.57 | $118.57 | $287.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $122.08 / $280.39
| Professional | | $43.65 | $122.08 | $280.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.75 / $1,132.80 / $1,331.63
| Professional | | $586.75 | $1,132.80 | $1,331.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.23 / $174.68 / $320.41
| Professional | | $123.23 | $174.68 | $320.41 |