- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.68 / $139.06 / $192.36
| Professional | | $112.68 | $139.06 | $192.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.69 / $255.43 / $432.30
| Professional | | $216.69 | $255.43 | $432.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.77 / $163.93 / $242.53
| Professional | | $113.77 | $163.93 | $242.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.77 / $175.91 / $242.53
| Professional | | $113.77 | $175.91 | $242.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.13 / $181.68 / $493.23
| Professional | | $138.13 | $181.68 | $493.23 |