- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $107.15 / $169.82
| Professional | | $75.86 | $107.15 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $194.98 / $204.17
| Professional | | $81.28 | $194.98 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $117.49 / $223.87
| Professional | | $81.28 | $117.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $131.83 / $181.97
| Professional | | $81.28 | $131.83 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $109.65 / $199.53
| Professional | | $72.44 | $109.65 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $117.49 / $158.49
| Professional | | $87.10 | $117.49 | $158.49 |