- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $229.09 / $263.03
| Professional | | $97.72 | $229.09 | $263.03 |
- 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
- $257.04 / $269.15 / $331.13
| Professional | | $257.04 | $269.15 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $154.88 / $158.49
| Professional | | $154.88 | $154.88 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $123.03 / $151.36
| Professional | | $109.65 | $123.03 | $151.36 |