- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $114.82 / $239.88
| Professional | | $81.28 | $114.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $144.54 / $213.80
| Professional | | $100.00 | $144.54 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $141.25 / $239.88
| Professional | | $123.03 | $141.25 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $151.36 / $218.78
| Professional | | $123.03 | $151.36 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $125.89 / $316.23
| Professional | | $81.28 | $125.89 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $147.91 / $234.42
| Professional | | $123.03 | $147.91 | $234.42 |