- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.08 / $100.08 / $152.50
| Professional | | $100.08 | $100.08 | $152.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.98 / $109.31 / $157.94
| Professional | | $95.98 | $109.31 | $157.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.15 / $132.77 / $173.56
| Professional | | $100.15 | $132.77 | $173.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.24 / $114.94 / $176.32
| Professional | | $89.24 | $114.94 | $176.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.08 / $100.08 / $152.50
| Professional | | $100.08 | $100.08 | $152.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.25 / $125.54 / $158.49
| Professional | | $109.25 | $125.54 | $158.49 |