- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.08 / $168.08 / $168.08
| Professional | | $110.08 | $168.08 | $168.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.05 / $224.88 / $310.52
| Professional | | $149.05 | $224.88 | $310.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.84 / $254.64 / $417.00
| Professional | | $150.84 | $254.64 | $417.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.12 / $254.37 / $424.01
| Professional | | $166.12 | $254.37 | $424.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.08 / $110.08 / $168.08
| Professional | | $110.08 | $110.08 | $168.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.27 / $297.11 / $412.16
| Professional | | $201.27 | $297.11 | $412.16 |