- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.34 / $131.36 / $224.47
| Professional | | $94.34 | $131.36 | $224.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.47 / $163.68 / $254.93
| Professional | | $111.47 | $163.68 | $254.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.26 / $168.90 / $268.63
| Professional | | $118.26 | $168.90 | $268.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.12 / $1,044.24 / $1,234.80
| Professional | | $765.12 | $1,044.24 | $1,234.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.62 / $158.60 / $292.68
| Professional | | $123.62 | $158.60 | $292.68 |