- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.45 / $137.82 / $174.42
| Professional | | $109.45 | $137.82 | $174.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.73 / $201.26 / $537.55
| Professional | | $170.73 | $201.26 | $537.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.62 / $193.20 / $329.23
| Professional | | $142.62 | $193.20 | $329.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.08 / $193.69 / $291.62
| Professional | | $153.08 | $193.69 | $291.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.85 / $206.78 / $601.12
| Professional | | $195.85 | $206.78 | $601.12 |