- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.93 / $119.21 / $166.08
| Professional | | $76.93 | $119.21 | $166.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.56 / $157.60 / $229.62
| Professional | | $105.56 | $157.60 | $229.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.81 / $183.74 / $295.77
| Professional | | $104.81 | $183.74 | $295.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $187.28 / $313.67
| Professional | | $120.36 | $187.28 | $313.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.93 / $119.21 / $258.02
| Professional | | $76.93 | $119.21 | $258.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.57 / $206.00 / $305.88
| Professional | | $124.57 | $206.00 | $305.88 |