- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.67 / $116.67 / $127.06
| Professional | | $116.67 | $116.67 | $127.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.32 / $245.56 / $290.13
| Professional | | $225.32 | $245.56 | $290.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.69 / $222.84 / $359.71
| Professional | | $141.69 | $222.84 | $359.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.46 / $218.18 / $303.50
| Professional | | $119.46 | $218.18 | $303.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.81 / $232.38 / $317.08
| Professional | | $127.81 | $232.38 | $317.08 |