- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.60 / $214.84 / $359.30
| Professional | | $110.60 | $214.84 | $359.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.26 / $216.25 / $355.55
| Professional | | $128.26 | $216.25 | $355.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.96 / $147.62 / $187.35
| Professional | | $115.96 | $147.62 | $187.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.19 / $199.93 / $339.05
| Professional | | $131.19 | $199.93 | $339.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.97 / $248.04 / $355.58
| Professional | | $191.97 | $248.04 | $355.58 |