- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.10 / $91.00 / $99.43
| Professional | | $90.10 | $91.00 | $99.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.59 / $114.65 / $172.19
| Professional | | $88.59 | $114.65 | $172.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.70 / $96.70 / $96.70
| Facility | | $96.70 | $96.70 | $96.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.93 / $131.22 / $191.71
| Professional | | $94.93 | $131.22 | $191.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.95 / $119.70 / $238.63
| Professional | | $92.95 | $119.70 | $238.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.10 / $91.00 / $99.43
| Professional | | $90.10 | $91.00 | $99.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.49 / $135.31 / $177.44
| Professional | | $85.49 | $135.31 | $177.44 |