- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $141.25 / $251.19
| Professional | | $100.00 | $141.25 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $169.82 / $288.40
| Professional | | $104.71 | $169.82 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $134.90 / $173.78
| Professional | | $79.43 | $134.90 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $134.90 / $251.19
| Professional | | $91.20 | $134.90 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $131.83 / $173.78
| Professional | | $93.33 | $131.83 | $173.78 |