- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.50 / $103.07 / $103.07
| Professional | | $94.50 | $103.07 | $103.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.51 / $101.68 / $167.77
| Professional | | $91.51 | $101.68 | $167.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.87 / $313.93 / $503.96
| Professional | | $116.87 | $313.93 | $503.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.08 / $243.03 / $243.03
| Professional | | $107.08 | $243.03 | $243.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.08 / $145.43 / $307.76
| Professional | | $77.08 | $145.43 | $307.76 |