- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.89 / $117.56 / $117.56
| Professional | | $101.89 | $117.56 | $117.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.40 / $125.40 / $142.96
| Professional | | $125.40 | $125.40 | $142.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.08 / $83.08 / $83.08
| Professional | | $83.08 | $83.08 | $83.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.75 / $180.26 / $235.13
| Professional | | $156.75 | $180.26 | $235.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.84 / $70.54 / $137.94
| Professional | | $65.84 | $70.54 | $137.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.38 / $78.38 / $78.38
| Professional | | $78.38 | $78.38 | $78.38 |