- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.17 / $133.83 / $161.65
| Professional | | $106.17 | $133.83 | $161.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.11 / $107.11 / $107.11
| Professional | | $107.11 | $107.11 | $107.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.26 / $196.26 / $196.26
| Professional | | $196.26 | $196.26 | $196.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.73 / $163.69 / $209.56
| Professional | | $101.73 | $163.69 | $209.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.67 / $161.86 / $832.84
| Professional | | $126.67 | $161.86 | $832.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.57 / $156.15 / $232.13
| Professional | | $121.57 | $156.15 | $232.13 |