- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.10 / $118.79 / $151.25
| Professional | | $98.10 | $118.79 | $151.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.30 / $93.30 / $660.00
| Professional | | $93.30 | $93.30 | $660.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.77 / $203.71 / $396.20
| Professional | | $108.77 | $203.71 | $396.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.64 / $334.77 / $334.77
| Professional | | $243.64 | $334.77 | $334.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $191.39 / $405.31
| Professional | | $106.97 | $191.39 | $405.31 |