- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.40 / $128.77 / $555.00
| Professional | | $90.40 | $128.77 | $555.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.62 / $191.69 / $468.74
| Professional | | $162.62 | $191.69 | $468.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.75 / $176.36 / $227.88
| Professional | | $115.75 | $176.36 | $227.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.00 / $174.94 / $227.88
| Professional | | $110.00 | $174.94 | $227.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.03 / $174.88 / $530.39
| Professional | | $148.03 | $174.88 | $530.39 |