- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.47 / $139.47 / $139.47
| Professional | | $139.47 | $139.47 | $139.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.60 / $146.53 / $450.92
| Professional | | $140.60 | $146.53 | $450.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.29 / $178.87 / $412.50
| Professional | | $125.29 | $178.87 | $412.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.98 / $272.18 / $272.18
| Professional | | $123.98 | $272.18 | $272.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.02 / $185.76 / $353.70
| Professional | | $113.02 | $185.76 | $353.70 |