- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.64 / $112.31 / $126.60
| Professional | | $73.64 | $112.31 | $126.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.00 / $100.67 / $138.38
| Professional | | $82.00 | $100.67 | $138.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.43 / $142.12 / $175.60
| Professional | | $125.43 | $142.12 | $175.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.68 / $135.31 / $195.68
| Professional | | $112.68 | $135.31 | $195.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.34 / $115.85 / $182.80
| Professional | | $93.34 | $115.85 | $182.80 |