- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.82 / $137.82 / $171.12
| Professional | | $137.82 | $137.82 | $171.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.53 / $213.72 / $329.37
| Professional | | $168.53 | $213.72 | $329.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.95 / $261.69 / $365.01
| Professional | | $215.95 | $261.69 | $365.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.76 / $257.30 / $381.18
| Professional | | $214.76 | $257.30 | $381.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.82 / $171.12 / $196.78
| Professional | | $137.82 | $171.12 | $196.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.00 / $253.97 / $386.60
| Professional | | $172.00 | $253.97 | $386.60 |