- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.38 / $166.52 / $213.93
| Professional | | $142.38 | $166.52 | $213.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.43 / $261.80 / $325.06
| Professional | | $164.43 | $261.80 | $325.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.10 / $211.14 / $296.20
| Professional | | $198.10 | $211.14 | $296.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.56 / $129.56 / $183.37
| Professional | | $129.56 | $129.56 | $183.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.60 / $258.38 / $314.11
| Professional | | $208.60 | $258.38 | $314.11 |