- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.28 / $136.65 / $136.65
| Professional | | $120.28 | $136.65 | $136.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.77 / $165.77 / $498.27
| Professional | | $165.77 | $165.77 | $498.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.81 / $148.71 / $642.21
| Professional | | $100.81 | $148.71 | $642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.71 / $349.81 / $349.81
| Professional | | $164.71 | $349.81 | $349.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.45 / $283.25 / $495.94
| Professional | | $107.45 | $283.25 | $495.94 |