- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.56 / $227.77 / $315.66
| Professional | | $114.56 | $227.77 | $315.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.64 / $224.06 / $324.63
| Professional | | $85.64 | $224.06 | $324.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.49 / $200.77 / $297.64
| Professional | | $104.49 | $200.77 | $297.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.33 / $161.47 / $222.37
| Professional | | $129.33 | $161.47 | $222.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.06 / $231.66 / $355.52
| Professional | | $174.06 | $231.66 | $355.52 |