- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.20 / $117.54 / $247.84
| Professional | | $96.20 | $117.54 | $247.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.79 / $148.41 / $272.97
| Professional | | $103.79 | $148.41 | $272.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.41 / $168.81 / $282.42
| Professional | | $110.41 | $168.81 | $282.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.29 / $167.97 / $297.43
| Professional | | $121.29 | $167.97 | $297.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.18 / $184.09 / $214.12
| Professional | | $147.18 | $184.09 | $214.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.24 / $151.94 / $268.39
| Professional | | $101.24 | $151.94 | $268.39 |