- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $144.54 / $239.88
| Professional | | $102.33 | $144.54 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $251.19 / $251.19
| Professional | | $162.18 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $162.18 / $275.42
| Professional | | $104.71 | $162.18 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $169.82 / $251.19
| Professional | | $112.20 | $169.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $147.91 / $257.04
| Professional | | $97.72 | $147.91 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $154.88 / $213.80
| Professional | | $114.82 | $154.88 | $213.80 |