- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.52 / $101.63 / $172.49
| Professional | | $71.52 | $101.63 | $172.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.32 / $132.55 / $203.96
| Professional | | $87.32 | $132.55 | $203.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.22 / $137.41 / $221.40
| Professional | | $94.22 | $137.41 | $221.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.55 / $917.60 / $1,091.48
| Professional | | $626.55 | $917.60 | $1,091.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.70 / $132.82 / $235.61
| Professional | | $99.70 | $132.82 | $235.61 |