- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.63 / $126.36 / $126.36
| Professional | | $65.63 | $126.36 | $126.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.69 / $141.02 / $213.65
| Professional | | $118.69 | $141.02 | $213.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.30 / $155.99 / $234.02
| Professional | | $120.30 | $155.99 | $234.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.42 / $160.24 / $245.82
| Professional | | $124.42 | $160.24 | $245.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.63 / $126.36 / $126.36
| Professional | | $65.63 | $126.36 | $126.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.72 / $159.49 / $214.77
| Professional | | $132.72 | $159.49 | $214.77 |