- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $141.25 / $245.47
| Professional | | $100.00 | $141.25 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $147.91 / $204.17
| Professional | | $107.15 | $147.91 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $177.83 / $234.42
| Professional | | $120.23 | $177.83 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $173.78 / $1,174.90
| Professional | | $128.82 | $173.78 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $131.83 / $194.98
| Professional | | $97.72 | $131.83 | $194.98 |