- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $117.49 / $501.19
| Professional | | $81.28 | $117.49 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $141.25
| Professional | | $58.88 | $58.88 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $208.93 / $208.93
| Professional | | $199.53 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $74.13 / $158.49
| Professional | | $47.86 | $74.13 | $158.49 |