- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.83 / $194.10 / $194.10
| Professional | | $107.83 | $194.10 | $194.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.33 / $236.67 / $346.96
| Professional | | $145.33 | $236.67 | $346.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.66 / $264.62 / $481.57
| Professional | | $148.66 | $264.62 | $481.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.18 / $281.52 / $473.98
| Professional | | $168.18 | $281.52 | $473.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.83 / $107.83 / $194.10
| Professional | | $107.83 | $107.83 | $194.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.92 / $335.69 / $466.92
| Professional | | $195.92 | $335.69 | $466.92 |