- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.54 / $117.89 / $287.64
| Professional | | $93.54 | $117.89 | $287.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.95 / $263.73 / $415.50
| Professional | | $257.95 | $263.73 | $415.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.42 / $172.34 / $202.27
| Professional | | $103.42 | $172.34 | $202.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.10 / $170.20 / $202.27
| Professional | | $93.10 | $170.20 | $202.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.30 / $157.16 / $477.03
| Professional | | $135.30 | $157.16 | $477.03 |