- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.22 / $113.49 / $177.44
| Professional | | $93.22 | $113.49 | $177.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.38 / $143.38 / $156.30
| Professional | | $143.38 | $143.38 | $156.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.00 / $167.24 / $384.25
| Professional | | $108.00 | $167.24 | $384.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.25 / $129.54 / $324.76
| Professional | | $105.25 | $129.54 | $324.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.00 / $133.75 / $239.09
| Professional | | $95.00 | $133.75 | $239.09 |