- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.56 / $133.38 / $305.06
| Professional | | $110.56 | $133.38 | $305.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $162.97
| Professional | | $162.97 | $162.97 | $162.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.46 / $200.83 / $433.53
| Professional | | $109.46 | $200.83 | $433.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.09 / $165.63 / $880.77
| Professional | | $114.09 | $165.63 | $880.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.99 / $160.72 / $316.69
| Professional | | $108.99 | $160.72 | $316.69 |