- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.84 / $99.46 / $106.41
| Professional | | $69.84 | $99.46 | $106.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.71 / $136.71 / $136.71
| Professional | | $136.71 | $136.71 | $136.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.03 / $101.83 / $136.71
| Professional | | $80.03 | $101.83 | $136.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.76 / $110.65 / $153.13
| Professional | | $73.76 | $110.65 | $153.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.75 / $113.86 / $131.19
| Professional | | $70.75 | $113.86 | $131.19 |