- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.43 / $125.47 / $258.13
| Professional | | $80.43 | $125.47 | $258.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.52 / $167.37 / $229.04
| Professional | | $88.52 | $167.37 | $229.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.13 / $187.00 / $300.14
| Professional | | $128.13 | $187.00 | $300.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.64 / $174.03 / $217.95
| Professional | | $110.64 | $174.03 | $217.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.52 / $203.48 / $376.61
| Professional | | $108.52 | $203.48 | $376.61 |