- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.00 / $147.29 / $157.53
| Professional | | $130.00 | $147.29 | $157.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.17 / $179.73 / $265.68
| Professional | | $165.17 | $179.73 | $265.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.88 / $220.93 / $315.70
| Professional | | $173.88 | $220.93 | $315.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.30 / $210.32 / $322.64
| Professional | | $163.30 | $210.32 | $322.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.53 / $147.29 / $157.53
| Professional | | $128.53 | $147.29 | $157.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.83 / $212.07 / $291.20
| Professional | | $136.83 | $212.07 | $291.20 |