- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.17 / $114.00 / $222.50
| Professional | | $104.17 | $114.00 | $222.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.55 / $125.48 / $199.51
| Professional | | $101.55 | $125.48 | $199.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.73 / $147.25 / $293.62
| Professional | | $103.73 | $147.25 | $293.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.73 / $109.19 / $239.68
| Professional | | $103.73 | $109.19 | $239.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.50 / $130.61 / $269.54
| Professional | | $101.50 | $130.61 | $269.54 |