- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.61 / $110.96 / $131.83
| Professional | | $75.61 | $110.96 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.93 / $165.75 / $214.48
| Professional | | $114.93 | $165.75 | $214.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.07 / $171.97 / $300.77
| Professional | | $127.07 | $171.97 | $300.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.87 / $159.78 / $256.35
| Professional | | $153.87 | $159.78 | $256.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.90 / $165.99 / $330.20
| Professional | | $112.90 | $165.99 | $330.20 |