- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $123.03 / $213.80
| Professional | | $87.10 | $123.03 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $218.78 / $223.87
| Professional | | $114.82 | $218.78 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $194.98 / $251.19
| Professional | | $128.82 | $194.98 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $257.04
| Professional | | $251.19 | $251.19 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $134.90 / $239.88
| Professional | | $104.71 | $134.90 | $239.88 |