- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.16 / $128.53 / $174.92
| Professional | | $96.16 | $128.53 | $174.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.81 / $111.50 / $171.68
| Professional | | $92.81 | $111.50 | $171.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.88 / $146.02 / $152.26
| Professional | | $136.88 | $146.02 | $152.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.15 / $123.68 / $194.67
| Professional | | $94.15 | $123.68 | $194.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.75 / $110.07 / $171.37
| Professional | | $84.75 | $110.07 | $171.37 |