- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $107.15 / $194.98
| Professional | | $74.13 | $107.15 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $125.89 / $223.87
| Professional | | $102.33 | $125.89 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $134.90 / $213.80
| Professional | | $89.13 | $134.90 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,096.48 / $1,096.48
| Professional | | $912.01 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $117.49 / $204.17
| Professional | | $75.86 | $117.49 | $204.17 |