- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.88 / $124.37 / $220.93
| Professional | | $87.88 | $124.37 | $220.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.49 / $163.60 / $233.93
| Professional | | $109.49 | $163.60 | $233.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $116.14 / $209.70
| Professional | | $32.34 | $116.14 | $209.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.49 / $163.60 / $233.93
| Professional | | $109.49 | $163.60 | $233.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.00 / $182.00 / $278.87
| Professional | | $144.00 | $182.00 | $278.87 |