- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.94 / $121.94 / $211.16
| Professional | | $121.94 | $121.94 | $211.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.11 / $160.57 / $254.25
| Professional | | $140.11 | $160.57 | $254.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.58 / $184.23 / $263.94
| Professional | | $152.58 | $184.23 | $263.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.79 / $173.60 / $266.31
| Professional | | $134.79 | $173.60 | $266.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.94 / $121.94 / $211.16
| Professional | | $121.94 | $121.94 | $211.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.19 / $171.62 / $242.82
| Professional | | $141.19 | $171.62 | $242.82 |