- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.27 / $166.13 / $322.52
| Professional | | $90.27 | $166.13 | $322.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.71 / $212.01 / $380.92
| Professional | | $111.71 | $212.01 | $380.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.99 / $229.77 / $436.68
| Professional | | $126.99 | $229.77 | $436.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.06 / $277.41 / $349.22
| Professional | | $194.06 | $277.41 | $349.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.06 / $261.12 / $688.05
| Professional | | $144.06 | $261.12 | $688.05 |