- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.28 / $152.33 / $212.84
| Professional | | $121.28 | $152.33 | $212.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.60 / $195.60 / $195.60
| Professional | | $195.60 | $195.60 | $195.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $193.12 / $309.14
| Professional | | $134.88 | $193.12 | $309.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $221.61 / $369.28
| Professional | | $134.88 | $221.61 | $369.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.11 / $227.15 / $272.58
| Professional | | $194.11 | $227.15 | $272.58 |