- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $114.82 / $194.98
| Professional | | $81.28 | $114.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $158.49 / $223.87
| Professional | | $81.28 | $158.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $186.21 / $323.59
| Professional | | $112.20 | $186.21 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $177.83 / $323.59
| Professional | | $100.00 | $177.83 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $158.49 / $309.03
| Professional | | $100.00 | $158.49 | $309.03 |