- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.20 / $200.02 / $200.02
| Professional | | $118.20 | $200.02 | $200.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.08 / $224.12 / $340.18
| Professional | | $188.08 | $224.12 | $340.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.25 / $248.11 / $372.03
| Professional | | $191.25 | $248.11 | $372.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.74 / $254.67 / $390.67
| Professional | | $197.74 | $254.67 | $390.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.20 / $200.02 / $200.02
| Professional | | $118.20 | $200.02 | $200.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.43 / $260.70 / $342.96
| Professional | | $217.43 | $260.70 | $342.96 |