- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $114.82 / $199.53
| Professional | | $77.62 | $114.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $138.04 / $194.98
| Professional | | $95.50 | $138.04 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $147.91 / $251.19
| Professional | | $95.50 | $147.91 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $162.18 / $630.96
| Professional | | $91.20 | $162.18 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $162.18 / $269.15
| Professional | | $91.20 | $162.18 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $128.82 / $229.09
| Professional | | $81.28 | $128.82 | $229.09 |