- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.15 / $118.93 / $402.18
| Professional | | $100.15 | $118.93 | $402.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.59 / $198.89 / $205.87
| Professional | | $157.59 | $198.89 | $205.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.46 / $159.50 / $267.39
| Professional | | $117.46 | $159.50 | $267.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.46 / $159.50 / $267.39
| Professional | | $117.46 | $159.50 | $267.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.96 / $167.94 / $343.11
| Professional | | $125.96 | $167.94 | $343.11 |