- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $169.82 / $257.04
| Professional | | $97.72 | $169.82 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $199.53
| Professional | | $177.83 | $177.83 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Professional | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $354.81
| Professional | | $269.15 | $269.15 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $120.23 / $169.82
| Professional | | $100.00 | $120.23 | $169.82 |