- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.55 / $105.55 / $109.77
| Professional | | $105.55 | $105.55 | $109.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.66 / $140.72 / $167.14
| Professional | | $126.66 | $140.72 | $167.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.76 / $163.52 / $590.36
| Professional | | $104.76 | $163.52 | $590.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.84 / $286.06 / $286.06
| Professional | | $161.84 | $286.06 | $286.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.44 / $140.72 / $301.99
| Professional | | $84.44 | $140.72 | $301.99 |