- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $144.54 / $234.42
| Professional | | $114.82 | $144.54 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $346.74 / $512.86
| Professional | | $144.54 | $346.74 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $204.17 / $346.74
| Professional | | $141.25 | $204.17 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $234.42 / $380.19
| Professional | | $162.18 | $234.42 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $213.80 / $371.54
| Professional | | $147.91 | $213.80 | $371.54 |