- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.45 / $109.76 / $131.83
| Professional | | $74.45 | $109.76 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.20 / $153.28 / $269.61
| Professional | | $111.20 | $153.28 | $269.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $92.55 / $200.64
| Professional | | $45.00 | $92.55 | $200.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.49 / $139.27 / $217.98
| Professional | | $92.49 | $139.27 | $217.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.55 / $113.44 / $213.12
| Professional | | $90.55 | $113.44 | $213.12 |