- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.92 / $121.85 / $138.44
| Professional | | $108.92 | $121.85 | $138.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.53 / $132.00 / $223.01
| Professional | | $115.53 | $132.00 | $223.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.10 / $146.26 / $229.15
| Professional | | $120.10 | $146.26 | $229.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.00 / $140.00 / $141.63
| Professional | | $130.00 | $140.00 | $141.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.75 / $151.92 / $241.32
| Professional | | $123.75 | $151.92 | $241.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.00 / $126.24 / $192.65
| Professional | | $103.00 | $126.24 | $192.65 |