- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.44 / $136.62 / $485.25
| Professional | | $101.44 | $136.62 | $485.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.60 / $282.60 / $545.59
| Professional | | $282.60 | $282.60 | $545.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.34 / $192.00 / $545.59
| Professional | | $118.34 | $192.00 | $545.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.65 / $208.91 / $545.59
| Professional | | $143.65 | $208.91 | $545.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.91 / $239.41 / $669.65
| Professional | | $161.91 | $239.41 | $669.65 |