- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.78 / $118.63 / $452.00
| Professional | | $93.78 | $118.63 | $452.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.53 / $194.53 / $267.24
| Professional | | $194.53 | $194.53 | $267.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.93 / $176.44 / $267.24
| Professional | | $104.93 | $176.44 | $267.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.28 / $165.29 / $224.12
| Professional | | $104.28 | $165.29 | $224.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.59 / $168.41 / $253.93
| Professional | | $98.59 | $168.41 | $253.93 |