- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.20 / $107.12 / $539.19
| Professional | | $96.20 | $107.12 | $539.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.15 / $166.15 / $190.34
| Professional | | $166.15 | $166.15 | $190.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.10 / $161.79 / $192.64
| Professional | | $85.10 | $161.79 | $192.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.70 / $166.15 / $231.70
| Professional | | $108.70 | $166.15 | $231.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.11 / $184.81 / $218.46
| Professional | | $155.11 | $184.81 | $218.46 |