- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.12 / $108.16 / $184.07
| Professional | | $76.12 | $108.16 | $184.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.35 / $138.91 / $218.10
| Professional | | $91.35 | $138.91 | $218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.37 / $143.47 / $230.27
| Professional | | $96.37 | $143.47 | $230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $632.48 / $918.72 / $1,090.28
| Professional | | $632.48 | $918.72 | $1,090.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.45 / $132.31 / $254.92
| Professional | | $106.45 | $132.31 | $254.92 |