- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.78 / $121.78 / $161.78
| Professional | | $121.78 | $121.78 | $161.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.02 / $143.94 / $216.26
| Professional | | $129.02 | $143.94 | $216.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.26 / $157.47 / $224.15
| Professional | | $126.26 | $157.47 | $224.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.20 / $157.38 / $241.44
| Professional | | $122.20 | $157.38 | $241.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.78 / $121.78 / $161.78
| Professional | | $121.78 | $121.78 | $161.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.61 / $132.69 / $208.75
| Professional | | $102.61 | $132.69 | $208.75 |