- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $196.41 / $196.41
| Professional | | $151.16 | $196.41 | $196.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.25 / $167.53 / $248.12
| Professional | | $136.25 | $167.53 | $248.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.55 / $207.57 / $325.77
| Professional | | $165.55 | $207.57 | $325.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.68 / $159.93 / $248.85
| Professional | | $143.68 | $159.93 | $248.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $196.41 / $196.41
| Professional | | $151.16 | $196.41 | $196.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.72 / $199.38 / $273.64
| Professional | | $172.72 | $199.38 | $273.64 |