- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $154.88 / $295.12
| Professional | | $100.00 | $154.88 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $199.53 / $380.19
| Professional | | $123.03 | $199.53 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $186.21 / $316.23
| Professional | | $114.82 | $186.21 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $288.40 / $407.38
| Professional | | $5.01 | $288.40 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $144.54 / $288.40
| Professional | | $95.50 | $144.54 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,288.25
| Professional | | $1,096.48 | $1,096.48 | $1,288.25 |