- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.25 / $121.25 / $162.26
| Professional | | $113.25 | $121.25 | $162.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.30 / $93.30 / $128.75
| Professional | | $79.30 | $93.30 | $128.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.64 / $132.99 / $161.90
| Professional | | $115.64 | $132.99 | $161.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.88 / $144.44 / $208.57
| Professional | | $107.88 | $144.44 | $208.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.08 / $133.97 / $222.68
| Professional | | $106.08 | $133.97 | $222.68 |