- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.39 / $169.30 / $213.64
| Professional | | $98.39 | $169.30 | $213.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.31 / $171.03 / $262.72
| Professional | | $106.31 | $171.03 | $262.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.62 / $189.47 / $376.31
| Professional | | $111.62 | $189.47 | $376.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.53 / $187.00 / $323.89
| Professional | | $112.53 | $187.00 | $323.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.59 / $170.54 / $220.73
| Professional | | $104.59 | $170.54 | $220.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.12 / $261.75 / $346.47
| Professional | | $138.12 | $261.75 | $346.47 |