- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.16 / $139.32 / $176.46
| Professional | | $114.16 | $139.32 | $176.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.47 / $186.34 / $412.34
| Professional | | $107.47 | $186.34 | $412.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.26 / $147.52 / $199.15
| Professional | | $103.26 | $147.52 | $199.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.26 / $103.26 / $103.26
| Professional | | $103.26 | $103.26 | $103.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.11 / $97.46 / $206.53
| Professional | | $52.11 | $97.46 | $206.53 |