- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.73 / $91.25 / $131.13
| Professional | | $68.73 | $91.25 | $131.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.34 / $130.47 / $220.72
| Professional | | $93.34 | $130.47 | $220.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.63 / $138.44 / $216.30
| Professional | | $106.63 | $138.44 | $216.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.72 / $838.72 / $1,093.88
| Professional | | $838.72 | $838.72 | $1,093.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.09 / $121.54 / $230.12
| Professional | | $93.09 | $121.54 | $230.12 |