- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.61 / $193.54 / $397.54
| Professional | | $117.61 | $193.54 | $397.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $175.28
| Professional | | $175.28 | $175.28 | $175.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $396.00 / $479.85
| Professional | | $60.00 | $396.00 | $479.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.76 / $340.83 / $340.83
| Professional | | $270.76 | $340.83 | $340.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.63 / $182.18 / $274.43
| Professional | | $142.63 | $182.18 | $274.43 |