- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.04 / $123.86 / $327.52
| Professional | | $104.04 | $123.86 | $327.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.85 / $164.48 / $208.58
| Professional | | $109.85 | $164.48 | $208.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.32 / $186.42 / $207.66
| Professional | | $171.32 | $186.42 | $207.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $189.81
| Professional | | $32.34 | $32.34 | $189.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.32 / $208.61 / $215.07
| Professional | | $177.32 | $208.61 | $215.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.42 / $145.04 / $201.28
| Professional | | $106.42 | $145.04 | $201.28 |