- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.76 / $86.71 / $587.25
| Professional | | $82.76 | $86.71 | $587.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.52 / $143.25 / $347.10
| Professional | | $121.52 | $143.25 | $347.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.40 / $155.08 / $347.10
| Professional | | $101.40 | $155.08 | $347.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.52 / $115.50 / $164.02
| Professional | | $77.52 | $115.50 | $164.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.67 / $87.62 / $246.15
| Professional | | $54.67 | $87.62 | $246.15 |