- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.05 / $135.78 / $506.25
| Professional | | $74.05 | $135.78 | $506.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.04 / $175.69 / $369.57
| Professional | | $149.04 | $175.69 | $369.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.80 / $152.50 / $369.57
| Professional | | $116.80 | $152.50 | $369.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.48 / $152.50 / $293.62
| Professional | | $118.48 | $152.50 | $293.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.13 / $158.02 / $261.10
| Professional | | $115.13 | $158.02 | $261.10 |