- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.66 / $133.33 / $162.52
| Professional | | $104.66 | $133.33 | $162.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.13 / $136.62 / $277.01
| Professional | | $85.13 | $136.62 | $277.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.70 / $158.31 / $282.89
| Professional | | $104.70 | $158.31 | $282.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.06 / $151.35 / $397.60
| Professional | | $128.06 | $151.35 | $397.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.56 / $102.01 / $207.77
| Professional | | $58.56 | $102.01 | $207.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.82 / $152.15 / $316.43
| Professional | | $110.82 | $152.15 | $316.43 |