- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.64 / $110.64 / $115.07
| Professional | | $110.64 | $110.64 | $115.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.77 / $147.52 / $175.20
| Professional | | $132.77 | $147.52 | $175.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.75 / $171.02 / $618.80
| Professional | | $109.75 | $171.02 | $618.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.65 / $299.86 / $299.86
| Professional | | $169.65 | $299.86 | $299.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.51 / $118.02 / $316.56
| Professional | | $88.51 | $118.02 | $316.56 |