- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.29 / $140.26 / $173.73
| Professional | | $101.29 | $140.26 | $173.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.56 / $289.32 / $417.65
| Professional | | $223.56 | $289.32 | $417.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.41 / $287.85 / $508.45
| Professional | | $162.41 | $287.85 | $508.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.72 / $259.54 / $391.60
| Professional | | $155.72 | $259.54 | $391.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.72 / $276.60 / $391.60
| Professional | | $155.72 | $276.60 | $391.60 |