- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.18 / $153.76 / $199.43
| Professional | | $96.18 | $153.76 | $199.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.25 / $137.94 / $198.19
| Professional | | $117.25 | $137.94 | $198.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.20 / $197.88 / $323.64
| Professional | | $126.20 | $197.88 | $323.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.43 / $208.57 / $352.70
| Professional | | $129.43 | $208.57 | $352.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.67 / $153.76 / $199.43
| Professional | | $101.67 | $153.76 | $199.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.25 / $219.65 / $334.84
| Professional | | $143.25 | $219.65 | $334.84 |