- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $100.00 / $186.21
| Professional | | $53.70 | $100.00 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $354.81
| Professional | | $138.04 | $138.04 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $144.54 / $380.19
| Professional | | $69.18 | $144.54 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $151.36 / $269.15
| Professional | | $107.15 | $151.36 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $117.49 / $223.87
| Professional | | $61.66 | $117.49 | $223.87 |