- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $177.83 / $389.05
| Professional | | $112.20 | $177.83 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $199.53 / $363.08
| Professional | | $144.54 | $199.53 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $208.93 / $371.54
| Professional | | $134.90 | $208.93 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $190.55 / $537.03
| Professional | | $3.02 | $190.55 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $169.82 / $309.03
| Professional | | $107.15 | $169.82 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,659.59
| Professional | | $1,412.54 | $1,412.54 | $1,659.59 |