- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.56 / $111.22 / $176.41
| Professional | | $88.56 | $111.22 | $176.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.31 / $144.59 / $225.03
| Professional | | $102.31 | $144.59 | $225.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.67 / $149.13 / $235.24
| Professional | | $111.67 | $149.13 | $235.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.12 / $907.58 / $1,034.84
| Professional | | $783.12 | $907.58 | $1,034.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.83 / $125.61 / $245.73
| Professional | | $99.83 | $125.61 | $245.73 |