- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.21 / $127.90 / $151.10
| Professional | | $103.21 | $127.90 | $151.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.88 / $148.34 / $209.48
| Professional | | $132.88 | $148.34 | $209.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.03 / $145.13 / $241.82
| Professional | | $108.03 | $145.13 | $241.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.13 / $141.21 / $261.27
| Professional | | $108.13 | $141.21 | $261.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.21 / $127.90 / $151.10
| Professional | | $103.21 | $127.90 | $151.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.30 / $143.96 / $208.69
| Professional | | $102.30 | $143.96 | $208.69 |