- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.76 / $119.21 / $119.21
| Professional | | $113.76 | $119.21 | $119.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.87 / $116.05 / $472.54
| Professional | | $112.87 | $116.05 | $472.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.00 / $145.12 / $358.30
| Professional | | $77.00 | $145.12 | $358.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.24 / $136.09 / $136.09
| Professional | | $127.24 | $136.09 | $136.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.97 / $205.30 / $358.44
| Professional | | $104.97 | $205.30 | $358.44 |