- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.62 / $130.31 / $180.31
| Professional | | $103.62 | $130.31 | $180.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $565.13 / $565.13 / $565.13
| Professional | | $565.13 | $565.13 | $565.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.09 / $191.09 / $342.39
| Professional | | $136.09 | $191.09 | $342.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.79 / $204.62 / $303.02
| Professional | | $146.79 | $204.62 | $303.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.69 / $215.05 / $625.17
| Professional | | $203.69 | $215.05 | $625.17 |