- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.62 / $114.62 / $137.05
| Professional | | $114.62 | $114.62 | $137.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.00 / $176.25 / $176.25
| Professional | | $141.00 | $176.25 | $176.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.84 / $220.12 / $307.80
| Professional | | $118.84 | $220.12 | $307.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.51 / $220.12 / $347.08
| Professional | | $186.51 | $220.12 | $347.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.26 / $206.47 / $244.69
| Professional | | $153.26 | $206.47 | $244.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.38 / $175.88 / $293.14
| Professional | | $151.38 | $175.88 | $293.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.80 / $266.80 / $266.80
| Professional | | $226.80 | $266.80 | $266.80 |