- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.05 / $157.26 / $203.54
| Professional | | $82.05 | $157.26 | $203.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.27 / $147.27 / $147.27
| Professional | | $147.27 | $147.27 | $147.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.94 / $114.94 / $114.94
| Professional | | $114.94 | $114.94 | $114.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.46 / $239.46 / $239.46
| Professional | | $239.46 | $239.46 | $239.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.00 / $120.37 / $209.82
| Professional | | $112.00 | $120.37 | $209.82 |