- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.35 / $137.32 / $219.71
| Professional | | $101.35 | $137.32 | $219.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.00 / $114.38 / $165.98
| Professional | | $83.00 | $114.38 | $165.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.22 / $163.80 / $301.39
| Professional | | $106.22 | $163.80 | $301.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.80 / $65.80 / $65.80
| Professional | | $65.80 | $65.80 | $65.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.25 / $131.80 / $202.71
| Professional | | $92.25 | $131.80 | $202.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.24 / $174.24 / $317.93
| Professional | | $125.24 | $174.24 | $317.93 |