- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.05 / $170.60 / $255.69
| Professional | | $130.05 | $170.60 | $255.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.03 / $214.48 / $317.85
| Professional | | $164.03 | $214.48 | $317.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.55 / $155.39 / $199.70
| Professional | | $124.55 | $155.39 | $199.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.58 / $249.18 / $292.02
| Professional | | $206.58 | $249.18 | $292.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.54 / $180.45 / $360.00
| Professional | | $146.54 | $180.45 | $360.00 |