- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.77 / $104.16 / $104.16
| Professional | | $103.77 | $104.16 | $104.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.34 / $114.20 / $189.34
| Professional | | $92.34 | $114.20 | $189.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.81 / $146.22 / $224.85
| Professional | | $85.81 | $146.22 | $224.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.84 / $147.16 / $218.03
| Professional | | $122.84 | $147.16 | $218.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.77 / $109.43 / $121.47
| Professional | | $103.77 | $109.43 | $121.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.87 / $124.94 / $222.98
| Professional | | $91.87 | $124.94 | $222.98 |