- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.56 / $117.44 / $154.38
| Professional | | $77.56 | $117.44 | $154.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.51 / $125.15 / $179.31
| Professional | | $100.51 | $125.15 | $179.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.27 / $171.48 / $250.59
| Professional | | $115.27 | $171.48 | $250.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.30 / $159.11 / $282.39
| Professional | | $118.30 | $159.11 | $282.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.56 / $117.44 / $154.38
| Professional | | $77.56 | $117.44 | $154.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.64 / $160.56 / $253.10
| Professional | | $114.64 | $160.56 | $253.10 |