- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.08 / $107.81 / $248.01
| Professional | | $105.08 | $107.81 | $248.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.48 / $182.50 / $310.58
| Professional | | $114.48 | $182.50 | $310.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.85 / $153.85 / $153.85
| Professional | | $153.85 | $153.85 | $153.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.71 / $196.18 / $331.60
| Professional | | $118.71 | $196.18 | $331.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.08 / $107.67 / $248.01
| Professional | | $105.08 | $107.67 | $248.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.81 / $331.89 / $443.91
| Professional | | $248.81 | $331.89 | $443.91 |