- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.09 / $109.26 / $215.84
| Professional | | $76.09 | $109.26 | $215.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.52 / $129.40 / $170.74
| Professional | | $103.52 | $129.40 | $170.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.41 / $120.61 / $194.54
| Professional | | $79.41 | $120.61 | $194.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.08 / $133.86 / $929.60
| Professional | | $100.08 | $133.86 | $929.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.94 / $117.00 / $227.50
| Professional | | $98.94 | $117.00 | $227.50 |