- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.92 / $105.82 / $157.53
| Professional | | $89.92 | $105.82 | $157.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.21 / $117.47 / $185.72
| Professional | | $97.21 | $117.47 | $185.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.18 / $145.02 / $236.54
| Professional | | $107.18 | $145.02 | $236.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.44 / $173.70 / $897.92
| Professional | | $112.44 | $173.70 | $897.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.55 / $143.78 / $243.27
| Professional | | $105.55 | $143.78 | $243.27 |