- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.85 / $109.41 / $117.46
| Professional | | $93.85 | $109.41 | $117.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.72 / $114.34 / $115.50
| Professional | | $109.72 | $114.34 | $115.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.00 / $178.56 / $290.87
| Professional | | $135.00 | $178.56 | $290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.52 / $241.35 / $354.75
| Professional | | $148.52 | $241.35 | $354.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.31 / $212.35 / $319.11
| Professional | | $158.31 | $212.35 | $319.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.00 / $241.35 / $305.43
| Professional | | $151.00 | $241.35 | $305.43 |