- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $147.91 / $263.03
| Professional | | $100.00 | $147.91 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $177.83 / $316.23
| Professional | | $109.65 | $177.83 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $158.49 / $281.84
| Professional | | $102.33 | $158.49 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,288.25 / $1,288.25
| Professional | | $1,096.48 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $154.88 / $275.42
| Professional | | $95.50 | $154.88 | $275.42 |