- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $158.49 / $295.12
| Professional | | $102.33 | $158.49 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $251.19
| Professional | | $120.23 | $199.53 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $204.17 / $354.81
| Professional | | $131.83 | $204.17 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $316.23
| Professional | | $245.47 | $245.47 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $169.82 / $354.81
| Professional | | $102.33 | $169.82 | $354.81 |