- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $221.46
| Professional | | $100.00 | $100.00 | $221.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.25 / $120.50 / $338.39
| Professional | | $75.25 | $120.50 | $338.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.52 / $89.98 / $111.24
| Professional | | $69.52 | $89.98 | $111.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.73 / $143.75 / $206.71
| Professional | | $100.73 | $143.75 | $206.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.53 / $114.04 / $187.31
| Professional | | $85.53 | $114.04 | $187.31 |