- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.16 / $109.03 / $146.06
| Professional | | $98.16 | $109.03 | $146.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.78 / $460.78 / $460.78
| Professional | | $460.78 | $460.78 | $460.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.27 / $154.27 / $268.72
| Professional | | $123.27 | $154.27 | $268.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.72 / $155.19 / $232.23
| Professional | | $128.72 | $155.19 | $232.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.07 / $168.77 / $490.63
| Professional | | $145.07 | $168.77 | $490.63 |