- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $131.83 / $204.17
| Professional | | $112.20 | $131.83 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $144.54 / $213.80
| Professional | | $75.86 | $144.54 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $147.91 / $218.78
| Professional | | $104.71 | $147.91 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.83 / $123.03 / $194.98
| Professional | | $0.83 | $123.03 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.83 / $0.83 / $181.97
| Professional | | $0.83 | $0.83 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $123.03 / $194.98
| Professional | | $117.49 | $123.03 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $144.54 / $218.78
| Professional | | $100.00 | $144.54 | $218.78 |