- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.56 / $121.74 / $121.74
| Professional | | $113.56 | $121.74 | $121.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.77 / $185.05 / $1,028.11
| Professional | | $169.77 | $185.05 | $1,028.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.37 / $327.68 / $558.23
| Professional | | $144.37 | $327.68 | $558.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.43 / $144.37 / $295.52
| Professional | | $119.43 | $144.37 | $295.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.65 / $218.01 / $404.81
| Professional | | $136.65 | $218.01 | $404.81 |