- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $112.20 / $151.36
| Professional | | $93.33 | $112.20 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $151.36 / $213.80
| Professional | | $107.15 | $151.36 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $169.82 / $245.47
| Professional | | $120.23 | $169.82 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $125.89 / $457.09
| Professional | | $87.10 | $125.89 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $97.72 / $162.18
| Professional | | $87.10 | $97.72 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $151.36 / $251.19
| Professional | | $107.15 | $151.36 | $251.19 |