- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.26 / $113.02 / $215.84
| Professional | | $78.26 | $113.02 | $215.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.35 / $123.48 / $222.76
| Professional | | $86.35 | $123.48 | $222.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.97 / $151.21 / $259.93
| Professional | | $94.97 | $151.21 | $259.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.52 / $151.57 / $311.38
| Professional | | $103.52 | $151.57 | $311.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.27 / $150.34 / $224.17
| Professional | | $86.27 | $150.34 | $224.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.70 / $155.84 / $282.86
| Professional | | $99.70 | $155.84 | $282.86 |