- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.58 / $129.60 / $197.54
| Professional | | $106.58 | $129.60 | $197.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.28 / $157.65 / $242.65
| Professional | | $116.28 | $157.65 | $242.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.76 / $115.76 / $115.76
| Professional | | $115.76 | $115.76 | $115.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.48 / $138.69 / $212.24
| Professional | | $1.48 | $138.69 | $212.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.48 / $115.98 / $173.97
| Professional | | $1.48 | $115.98 | $173.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.84 / $160.86 / $260.43
| Professional | | $123.84 | $160.86 | $260.43 |