- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.04 / $129.47 / $154.75
| Professional | | $103.04 | $129.47 | $154.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.04 / $154.19 / $232.27
| Professional | | $119.04 | $154.19 | $232.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.51 / $109.51 / $109.51
| Professional | | $109.51 | $109.51 | $109.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.79 / $190.94 / $336.67
| Professional | | $105.79 | $190.94 | $336.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.19 / $203.24 / $356.90
| Professional | | $168.19 | $203.24 | $356.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.25 / $164.18 / $208.95
| Professional | | $149.25 | $164.18 | $208.95 |