- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $131.83 / $323.59
| Professional | | $104.71 | $131.83 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $208.93 / $239.88
| Professional | | $134.90 | $208.93 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $218.78 / $338.84
| Professional | | $158.49 | $218.78 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $223.87 / $426.58
| Professional | | $190.55 | $223.87 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $138.04 / $426.58
| Professional | | $107.15 | $138.04 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $190.55 / $338.84
| Professional | | $114.82 | $190.55 | $338.84 |