- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.15 / $162.58 / $243.44
| Professional | | $109.15 | $162.58 | $243.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.72 / $174.72 / $209.56
| Professional | | $174.72 | $174.72 | $209.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.98 / $189.84 / $271.63
| Professional | | $117.98 | $189.84 | $271.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.72 / $210.31 / $1,244.64
| Professional | | $152.72 | $210.31 | $1,244.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.97 / $173.09 / $322.29
| Professional | | $143.97 | $173.09 | $322.29 |