- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.57 / $100.85 / $357.00
| Professional | | $83.57 | $100.85 | $357.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.03 / $203.78 / $230.39
| Facility | | $199.03 | $203.78 | $230.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.02 / $94.45 / $118.53
| Professional | | $81.02 | $94.45 | $118.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.06 / $94.84 / $118.62
| Professional | | $81.06 | $94.84 | $118.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.45 / $118.31 / $362.47
| Professional | | $111.45 | $118.31 | $362.47 |