- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.49 / $126.54 / $207.17
| Professional | | $97.49 | $126.54 | $207.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.64 / $111.64 / $119.41
| Professional | | $111.64 | $111.64 | $119.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.71 / $227.00 / $267.86
| Professional | | $165.71 | $227.00 | $267.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.96 / $136.47 / $368.42
| Professional | | $116.96 | $136.47 | $368.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.00 / $119.01 / $162.15
| Professional | | $95.00 | $119.01 | $162.15 |