- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.21 / $146.33 / $581.66
| Professional | | $102.21 | $146.33 | $581.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.75 / $123.56 / $184.89
| Professional | | $108.75 | $123.56 | $184.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.89 / $168.43 / $257.27
| Professional | | $112.89 | $168.43 | $257.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.02 / $150.31 / $245.52
| Professional | | $2.02 | $150.31 | $245.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.38 / $151.96 / $255.75
| Professional | | $1.38 | $151.96 | $255.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.63 / $168.51 / $259.92
| Professional | | $129.63 | $168.51 | $259.92 |