- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $204.17 / $263.03
| Professional | | $97.72 | $204.17 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $346.74
| Professional | | $114.82 | $114.82 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $416.87 / $416.87
| Professional | | $398.11 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Professional | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $147.91 / $389.05
| Professional | | $93.33 | $147.91 | $389.05 |