- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $123.03 / $331.13
| Professional | | $95.50 | $123.03 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $131.83 / $257.04
| Professional | | $87.10 | $131.83 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $123.03 / $173.78
| Professional | | $100.00 | $123.03 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $125.89 / $263.03
| Professional | | $89.13 | $125.89 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $114.82 / $223.87
| Professional | | $87.10 | $114.82 | $223.87 |