- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $138.04 / $338.84
| Professional | | $93.33 | $138.04 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $177.83
| Professional | | $151.36 | $151.36 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $177.83 / $251.19
| Professional | | $100.00 | $177.83 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $190.55 / $229.09
| Professional | | $138.04 | $190.55 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $169.82 / $323.59
| Professional | | $128.82 | $169.82 | $323.59 |