- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.02 / $122.79 / $258.06
| Professional | | $109.02 | $122.79 | $258.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.84 / $207.92 / $342.72
| Professional | | $130.84 | $207.92 | $342.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.49 / $173.49 / $173.49
| Professional | | $173.49 | $173.49 | $173.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.19 / $223.43 / $373.92
| Professional | | $135.19 | $223.43 | $373.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.02 / $122.26 / $258.06
| Professional | | $109.02 | $122.26 | $258.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.36 / $365.07 / $445.52
| Professional | | $265.36 | $365.07 | $445.52 |