- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.81 / $107.81 / $112.13
| Professional | | $107.81 | $107.81 | $112.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.38 / $143.75 / $191.19
| Professional | | $129.38 | $143.75 | $191.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.92 / $166.85 / $603.16
| Professional | | $93.92 | $166.85 | $603.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.31 / $292.20 / $292.20
| Professional | | $165.31 | $292.20 | $292.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.25 / $112.85 / $320.52
| Professional | | $86.25 | $112.85 | $320.52 |