- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.86 / $141.24 / $272.06
| Professional | | $103.86 | $141.24 | $272.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.96 / $137.96 / $199.55
| Professional | | $137.96 | $137.96 | $199.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.88 / $195.52 / $245.62
| Professional | | $137.88 | $195.52 | $245.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $143.04 / $250.84
| Professional | | $32.34 | $143.04 | $250.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.88 / $200.33 / $285.92
| Professional | | $137.88 | $200.33 | $285.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.77 / $212.17 / $311.26
| Professional | | $148.77 | $212.17 | $311.26 |