- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.73 / $112.73 / $117.23
| Professional | | $112.73 | $112.73 | $117.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.27 / $150.30 / $199.90
| Professional | | $135.27 | $150.30 | $199.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.53 / $174.78 / $631.61
| Professional | | $109.53 | $174.78 | $631.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.85 / $305.51 / $305.51
| Professional | | $172.85 | $305.51 | $305.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.18 / $120.24 / $373.67
| Professional | | $90.18 | $120.24 | $373.67 |