- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.04 / $206.31 / $206.31
| Professional | | $163.04 | $206.31 | $206.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.52 / $239.84 / $301.32
| Professional | | $52.52 | $239.84 | $301.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.79 / $325.58 / $436.42
| Professional | | $170.79 | $325.58 | $436.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.04 / $195.06 / $269.16
| Professional | | $170.04 | $195.06 | $269.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.36 / $148.79 / $223.19
| Professional | | $34.36 | $148.79 | $223.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.08 / $218.87 / $298.19
| Professional | | $183.08 | $218.87 | $298.19 |