- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.84 / $123.88 / $215.32
| Professional | | $95.84 | $123.88 | $215.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.23 / $191.20 / $416.66
| Professional | | $107.23 | $191.20 | $416.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.45 / $221.25 / $271.93
| Professional | | $168.45 | $221.25 | $271.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.08 / $143.32 / $230.29
| Professional | | $87.08 | $143.32 | $230.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.54 / $142.00 / $314.52
| Professional | | $92.54 | $142.00 | $314.52 |