- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $114.82 / $245.47
| Professional | | $77.62 | $114.82 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $128.82 / $204.17
| Professional | | $81.28 | $128.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $147.91 / $245.47
| Professional | | $100.00 | $147.91 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $173.78 / $309.03
| Professional | | $100.00 | $173.78 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $131.83 / $331.13
| Professional | | $87.10 | $131.83 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $125.89 / $257.04
| Professional | | $83.18 | $125.89 | $257.04 |