- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.31 / $109.01 / $143.51
| Professional | | $96.31 | $109.01 | $143.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.63 / $446.63 / $446.63
| Professional | | $446.63 | $446.63 | $446.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.68 / $167.74 / $274.52
| Professional | | $101.68 | $167.74 | $274.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.97 / $168.48 / $274.52
| Professional | | $118.97 | $168.48 | $274.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.63 / $172.42 / $501.25
| Professional | | $137.63 | $172.42 | $501.25 |