- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.92 / $137.40 / $151.66
| Professional | | $114.92 | $137.40 | $151.66 |
- 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
- $122.09 / $220.12 / $307.04
| Professional | | $122.09 | $220.12 | $307.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.06 / $220.12 / $347.08
| Professional | | $186.06 | $220.12 | $347.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.76 / $226.17 / $245.32
| Professional | | $167.76 | $226.17 | $245.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.79 / $259.08 / $307.04
| Professional | | $151.79 | $259.08 | $307.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.80 / $266.80 / $266.80
| Professional | | $226.80 | $266.80 | $266.80 |