- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.04 / $119.93 / $154.50
| Professional | | $103.04 | $119.93 | $154.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.12 / $187.62 / $223.28
| Professional | | $118.12 | $187.62 | $223.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.81 / $143.19 / $203.45
| Professional | | $140.81 | $143.19 | $203.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.38 / $89.38 / $126.51
| Professional | | $89.38 | $89.38 | $126.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.11 / $198.07 / $229.76
| Professional | | $129.11 | $198.07 | $229.76 |