- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.12 / $124.13 / $237.16
| Professional | | $91.12 | $124.13 | $237.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.03 / $262.83 / $373.23
| Professional | | $103.03 | $262.83 | $373.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.71 / $151.35 / $297.20
| Professional | | $117.71 | $151.35 | $297.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.18 / $150.54 / $196.79
| Professional | | $113.18 | $150.54 | $196.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.55 / $157.55 / $161.54
| Professional | | $157.55 | $157.55 | $161.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.69 / $134.68 / $252.31
| Professional | | $93.69 | $134.68 | $252.31 |