- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.31 / $164.88 / $246.55
| Professional | | $106.31 | $164.88 | $246.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.96 / $183.83 / $352.68
| Professional | | $144.96 | $183.83 | $352.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.53 / $253.00 / $409.06
| Professional | | $144.53 | $253.00 | $409.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.22 / $256.80 / $432.35
| Professional | | $163.22 | $256.80 | $432.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.31 / $175.55 / $354.58
| Professional | | $106.31 | $175.55 | $354.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.55 / $280.73 / $432.35
| Professional | | $196.55 | $280.73 | $432.35 |