- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.25 / $100.25 / $115.75
| Professional | | $100.25 | $100.25 | $115.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.02 / $104.13 / $160.02
| Professional | | $93.02 | $104.13 | $160.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.42 / $119.34 / $165.49
| Professional | | $102.42 | $119.34 | $165.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.02 / $112.08 / $171.93
| Professional | | $87.02 | $112.08 | $171.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.25 / $100.25 / $115.75
| Professional | | $100.25 | $100.25 | $115.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.87 / $114.16 / $154.63
| Professional | | $96.87 | $114.16 | $154.63 |