- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.20 / $94.52 / $259.75
| Professional | | $94.20 | $94.52 | $259.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.22 / $260.22 / $260.22
| Professional | | $260.22 | $260.22 | $260.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.77 / $186.47 / $484.46
| Professional | | $105.77 | $186.47 | $484.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.37 / $279.70 / $441.87
| Professional | | $107.37 | $279.70 | $441.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.19 / $310.08 / $884.55
| Professional | | $288.19 | $310.08 | $884.55 |