- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $112.20 / $158.49
| Professional | | $97.72 | $112.20 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $128.82 / $194.98
| Professional | | $97.72 | $128.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $112.20 / $151.36
| Professional | | $91.20 | $112.20 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $144.54 / $239.88
| Professional | | $104.71 | $144.54 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $158.49 / $691.83
| Professional | | $102.33 | $158.49 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $128.82 / $229.09
| Professional | | $93.33 | $128.82 | $229.09 |