- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.26 / $171.12 / $211.38
| Professional | | $124.26 | $171.12 | $211.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.26 / $201.51 / $260.10
| Professional | | $137.26 | $201.51 | $260.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.28 / $220.76 / $381.11
| Professional | | $142.28 | $220.76 | $381.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.44 / $211.05 / $328.39
| Professional | | $143.44 | $211.05 | $328.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.10 / $166.38 / $211.38
| Professional | | $117.10 | $166.38 | $211.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.49 / $262.39 / $348.43
| Professional | | $180.49 | $262.39 | $348.43 |