- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.43 / $131.63 / $189.34
| Professional | | $111.43 | $131.63 | $189.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.39 / $166.96 / $262.42
| Professional | | $105.39 | $166.96 | $262.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.53 / $185.76 / $322.30
| Professional | | $117.53 | $185.76 | $322.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.17 / $185.52 / $321.33
| Professional | | $107.17 | $185.52 | $321.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.43 / $131.63 / $189.34
| Professional | | $111.43 | $131.63 | $189.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.94 / $163.41 / $344.33
| Professional | | $138.94 | $163.41 | $344.33 |