- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.23 / $104.50 / $421.00
| Professional | | $70.23 | $104.50 | $421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.55 / $123.55 / $322.82
| Professional | | $123.55 | $123.55 | $322.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.63 / $123.48 / $322.82
| Professional | | $75.63 | $123.48 | $322.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.63 / $151.85 / $322.82
| Professional | | $101.63 | $151.85 | $322.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.99 / $125.57 / $396.23
| Professional | | $113.99 | $125.57 | $396.23 |