- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.67 / $131.85 / $536.15
| Professional | | $92.67 | $131.85 | $536.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.61 / $152.61 / $192.43
| Professional | | $152.61 | $152.61 | $192.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.27 / $184.10 / $570.66
| Professional | | $126.27 | $184.10 | $570.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.57 / $184.10 / $570.66
| Professional | | $139.57 | $184.10 | $570.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.01 / $183.58 / $700.43
| Professional | | $132.01 | $183.58 | $700.43 |