- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.25 / $121.85 / $180.80
| Professional | | $113.25 | $121.85 | $180.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.50 / $121.85 / $377.40
| Professional | | $104.50 | $121.85 | $377.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.47 / $180.16 / $315.94
| Professional | | $120.47 | $180.16 | $315.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.00 / $141.63 / $160.49
| Professional | | $140.00 | $141.63 | $160.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $145.30 / $317.05
| Professional | | $112.32 | $145.30 | $317.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.05 / $1,017.38 / $1,017.38
| Professional | | $784.05 | $1,017.38 | $1,017.38 |