- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.32 / $128.53 / $340.78
| Professional | | $98.32 | $128.53 | $340.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.97 / $157.74 / $157.74
| Professional | | $141.97 | $157.74 | $157.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.91 / $149.28 / $243.96
| Professional | | $108.91 | $149.28 | $243.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.91 / $168.23 / $280.33
| Professional | | $108.91 | $168.23 | $280.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.44 / $177.84 / $210.44
| Professional | | $149.44 | $177.84 | $210.44 |