- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $107.15 / $223.87
| Professional | | $75.86 | $107.15 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $144.54 / $323.59
| Professional | | $83.18 | $144.54 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $173.78 / $239.88
| Professional | | $100.00 | $173.78 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $131.83 / $398.11
| Professional | | $75.86 | $131.83 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $112.20 / $263.03
| Professional | | $70.79 | $112.20 | $263.03 |