- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.19 / $109.92 / $147.05
| Professional | | $82.19 | $109.92 | $147.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.70 / $117.44 / $135.06
| Professional | | $105.70 | $117.44 | $135.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.00 / $139.00 / $317.89
| Professional | | $101.00 | $139.00 | $317.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.08 / $110.37 / $287.00
| Professional | | $89.08 | $110.37 | $287.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.15 / $149.65 / $357.53
| Professional | | $109.15 | $149.65 | $357.53 |