- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.91 / $122.54 / $159.27
| Professional | | $102.91 | $122.54 | $159.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.62 / $137.78 / $202.21
| Professional | | $84.62 | $137.78 | $202.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.95 / $112.40 / $146.93
| Professional | | $97.95 | $112.40 | $146.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.42 / $128.91 / $199.20
| Professional | | $103.42 | $128.91 | $199.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.94 / $114.47 / $195.58
| Professional | | $90.94 | $114.47 | $195.58 |