- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.19 / $110.19 / $110.19
| Professional | | $110.19 | $110.19 | $110.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.72 / $135.52 / $185.17
| Professional | | $104.72 | $135.52 | $185.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.62 / $160.46 / $266.26
| Professional | | $101.62 | $160.46 | $266.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.51 / $174.34 / $258.27
| Professional | | $145.51 | $174.34 | $258.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.19 / $110.19 / $110.19
| Professional | | $110.19 | $110.19 | $110.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.74 / $128.38 / $241.25
| Professional | | $99.74 | $128.38 | $241.25 |