- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.17 / $175.33 / $256.77
| Professional | | $106.17 | $175.33 | $256.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.81 / $164.81 / $164.81
| Professional | | $164.81 | $164.81 | $164.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.41 / $183.84 / $222.19
| Professional | | $163.41 | $183.84 | $222.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.13 / $137.24 / $223.56
| Professional | | $90.13 | $137.24 | $223.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.50 / $128.65 / $210.93
| Professional | | $88.50 | $128.65 | $210.93 |