- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.06 / $270.70 / $423.06
| Professional | | $103.06 | $270.70 | $423.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $347.79 / $553.52
| Professional | | $125.89 | $347.79 | $553.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.94 / $258.09 / $331.13
| Professional | | $205.94 | $258.09 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.13 / $205.91 / $451.73
| Professional | | $128.13 | $205.91 | $451.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.06 / $333.58 / $625.48
| Professional | | $275.06 | $333.58 | $625.48 |