- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.60 / $127.60 / $188.32
| Professional | | $103.60 | $127.60 | $188.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.51 / $163.84 / $277.95
| Professional | | $98.51 | $163.84 | $277.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.45 / $177.63 / $409.55
| Professional | | $122.45 | $177.63 | $409.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.13 / $166.02 / $242.97
| Professional | | $130.13 | $166.02 | $242.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.69 / $204.87 / $398.39
| Professional | | $117.69 | $204.87 | $398.39 |