- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.82 / $175.06 / $299.77
| Professional | | $93.82 | $175.06 | $299.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.14 / $192.14 / $287.88
| Professional | | $192.14 | $192.14 | $287.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.35 / $177.62 / $303.67
| Professional | | $105.35 | $177.62 | $303.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.47 / $260.43 / $1,312.96
| Professional | | $160.47 | $260.43 | $1,312.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.38 / $192.30 / $310.20
| Professional | | $150.38 | $192.30 | $310.20 |