- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.84 / $132.84 / $132.84
| Professional | | $132.84 | $132.84 | $132.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.37 / $132.19 / $194.61
| Professional | | $112.37 | $132.19 | $194.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.29 / $193.46 / $286.38
| Professional | | $109.29 | $193.46 | $286.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.93 / $183.23 / $271.44
| Professional | | $152.93 | $183.23 | $271.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.84 / $132.84 / $132.84
| Professional | | $132.84 | $132.84 | $132.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.10 / $153.25 / $261.58
| Professional | | $107.10 | $153.25 | $261.58 |