- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.28 / $113.28 / $166.16
| Professional | | $113.28 | $113.28 | $166.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.99 / $115.49 / $2,116.00
| Professional | | $106.99 | $115.49 | $2,116.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.87 / $150.47 / $407.73
| Professional | | $101.87 | $150.47 | $407.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.91 / $324.66 / $324.66
| Professional | | $148.91 | $324.66 | $324.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.13 / $169.61 / $421.90
| Professional | | $110.13 | $169.61 | $421.90 |