- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.03 / $223.27 / $373.68
| Professional | | $114.03 | $223.27 | $373.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.11 / $217.69 / $404.84
| Professional | | $117.11 | $217.69 | $404.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.39 / $210.11 / $405.13
| Professional | | $105.39 | $210.11 | $405.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.92 / $200.74 / $565.35
| Professional | | $98.92 | $200.74 | $565.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.84 / $187.91 / $337.61
| Professional | | $102.84 | $187.91 | $337.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.55 / $310.22 / $592.15
| Professional | | $205.55 | $310.22 | $592.15 |