- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.09 / $147.18 / $147.18
| Professional | | $123.09 | $147.18 | $147.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.25 / $332.25 / $332.25
| Professional | | $332.25 | $332.25 | $332.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.72 / $206.41 / $264.61
| Professional | | $153.72 | $206.41 | $264.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.51 / $206.45 / $332.25
| Professional | | $166.51 | $206.45 | $332.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.05 / $166.19 / $483.14
| Professional | | $129.05 | $166.19 | $483.14 |