- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.60 / $133.86 / $165.52
| Professional | | $103.60 | $133.86 | $165.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.05 / $170.84 / $332.96
| Professional | | $105.05 | $170.84 | $332.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.00 / $75.00 / $147.00
| Professional | | $72.00 | $75.00 | $147.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.56 / $108.27 / $217.06
| Professional | | $58.56 | $108.27 | $217.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.47 / $147.15 / $307.01
| Professional | | $95.47 | $147.15 | $307.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.77 / $880.77 / $997.35
| Professional | | $880.77 | $880.77 | $997.35 |