- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.93 / $117.20 / $186.24
| Professional | | $94.93 | $117.20 | $186.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.72 / $151.44 / $171.49
| Professional | | $128.72 | $151.44 | $171.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.97 / $145.50 / $234.92
| Professional | | $107.97 | $145.50 | $234.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.53 / $151.56 / $897.92
| Professional | | $115.53 | $151.56 | $897.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.16 / $133.34 / $191.21
| Professional | | $113.16 | $133.34 | $191.21 |