- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.30 / $187.03 / $465.12
| Professional | | $102.30 | $187.03 | $465.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.32 / $241.86 / $355.71
| Professional | | $132.32 | $241.86 | $355.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.72 / $361.36 / $690.88
| Professional | | $192.72 | $361.36 | $690.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.88 / $402.34 / $845.76
| Professional | | $170.88 | $402.34 | $845.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.50 / $422.33 / $817.64
| Professional | | $193.50 | $422.33 | $817.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.03 / $142.84 / $230.95
| Professional | | $102.03 | $142.84 | $230.95 |