- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.11 / $140.08 / $238.60
| Professional | | $104.11 | $140.08 | $238.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.62 / $166.57 / $325.39
| Professional | | $116.62 | $166.57 | $325.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.91 / $191.91 / $340.87
| Professional | | $131.91 | $191.91 | $340.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.28 / $161.84 / $229.32
| Professional | | $3.28 | $161.84 | $229.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.28 / $123.69 / $203.75
| Professional | | $3.28 | $123.69 | $203.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.07 / $206.60 / $356.03
| Professional | | $131.07 | $206.60 | $356.03 |