- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.60 / $121.86 / $121.86
| Professional | | $108.60 | $121.86 | $121.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.22 / $146.22 / $165.63
| Professional | | $146.22 | $146.22 | $165.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.38 / $189.27 / $561.86
| Professional | | $65.38 | $189.27 | $561.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.57 / $288.72 / $288.72
| Professional | | $179.57 | $288.72 | $288.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.72 / $112.02 / $304.80
| Professional | | $95.72 | $112.02 | $304.80 |