- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $117.49 / $213.80
| Professional | | $100.00 | $117.49 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $169.82 / $239.88
| Professional | | $102.33 | $169.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $194.98 / $331.13
| Professional | | $128.82 | $194.98 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $194.98 / $295.12
| Professional | | $125.89 | $194.98 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $169.82 / $309.03
| Professional | | $120.23 | $169.82 | $309.03 |