- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.44 / $132.59 / $181.88
| Professional | | $130.44 | $132.59 | $181.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.97 / $561.97 / $561.97
| Professional | | $561.97 | $561.97 | $561.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.40 / $211.58 / $353.70
| Professional | | $148.40 | $211.58 | $353.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.31 / $217.80 / $353.70
| Professional | | $151.31 | $217.80 | $353.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.45 / $218.53 / $645.80
| Professional | | $167.45 | $218.53 | $645.80 |