- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.79 / $139.47 / $251.27
| Professional | | $112.79 | $139.47 | $251.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.88 / $151.40 / $236.27
| Professional | | $128.88 | $151.40 | $236.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.70 / $115.57 / $144.86
| Professional | | $91.70 | $115.57 | $144.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.55 / $247.10 / $280.02
| Professional | | $198.55 | $247.10 | $280.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.60 / $140.40 / $199.88
| Professional | | $105.60 | $140.40 | $199.88 |