- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.11 / $140.76 / $192.46
| Professional | | $52.11 | $140.76 | $192.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.55 / $152.50 / $258.16
| Professional | | $56.55 | $152.50 | $258.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.37 / $141.66 / $280.83
| Professional | | $61.37 | $141.66 | $280.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.88 / $1,004.88 / $1,109.93
| Professional | | $1,004.88 | $1,004.88 | $1,109.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.90 / $160.96 / $300.92
| Professional | | $109.90 | $160.96 | $300.92 |