- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.38 / $190.94 / $389.05
| Professional | | $124.38 | $190.94 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.27 / $252.01 / $361.19
| Professional | | $167.27 | $252.01 | $361.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.57 / $294.54 / $473.73
| Professional | | $172.57 | $294.54 | $473.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.73 / $296.00 / $493.41
| Professional | | $193.73 | $296.00 | $493.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.38 / $204.61 / $404.46
| Professional | | $124.38 | $204.61 | $404.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.29 / $325.73 / $482.38
| Professional | | $227.29 | $325.73 | $482.38 |