- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.43 / $170.28 / $372.89
| Professional | | $105.43 | $170.28 | $372.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $228.40 / $335.28
| Professional | | $141.25 | $228.40 | $335.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.41 / $253.57 / $422.75
| Professional | | $143.41 | $253.57 | $422.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.41 / $272.05 / $458.02
| Professional | | $162.41 | $272.05 | $458.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.43 / $170.28 / $372.89
| Professional | | $105.43 | $170.28 | $372.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.70 / $271.01 / $448.33
| Professional | | $184.70 | $271.01 | $448.33 |