- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.57 / $97.65 / $258.00
| Professional | | $52.57 | $97.65 | $258.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.45 / $101.89 / $159.94
| Professional | | $64.45 | $101.89 | $159.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.30 / $85.78 / $115.57
| Professional | | $66.30 | $85.78 | $115.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.35 / $147.06 / $151.52
| Professional | | $132.35 | $147.06 | $151.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.29 / $100.96 / $133.97
| Professional | | $58.29 | $100.96 | $133.97 |