- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $154.88 / $295.12
| Professional | | $120.23 | $154.88 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $190.55 / $251.19
| Professional | | $114.82 | $190.55 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $173.78 / $295.12
| Professional | | $162.18 | $173.78 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $173.78 / $263.03
| Professional | | $141.25 | $173.78 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $181.97 / $380.19
| Professional | | $120.23 | $181.97 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $186.21 / $288.40
| Professional | | $141.25 | $186.21 | $288.40 |