- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.47 / $184.69 / $270.44
| Professional | | $130.47 | $184.69 | $270.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.56 / $294.55 / $507.38
| Professional | | $262.56 | $294.55 | $507.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.44 / $276.56 / $368.00
| Professional | | $163.44 | $276.56 | $368.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.55 / $258.44 / $976.46
| Professional | | $142.55 | $258.44 | $976.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.17 / $199.64 / $304.06
| Professional | | $121.17 | $199.64 | $304.06 |