- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.71 / $157.33 / $201.93
| Professional | | $131.71 | $157.33 | $201.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.28 / $246.34 / $292.08
| Professional | | $206.28 | $246.34 | $292.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.24 / $221.72 / $335.70
| Professional | | $141.24 | $221.72 | $335.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.24 / $221.72 / $335.70
| Professional | | $141.24 | $221.72 | $335.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.23 / $236.81 / $410.58
| Professional | | $164.23 | $236.81 | $410.58 |