- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.46 / $75.67 / $231.00
| Professional | | $41.46 | $75.67 | $231.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.83 / $101.18 / $202.20
| Professional | | $85.83 | $101.18 | $202.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.93 / $85.51 / $202.20
| Professional | | $64.93 | $85.51 | $202.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.93 / $85.62 / $164.29
| Professional | | $64.93 | $85.62 | $164.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.72 / $92.47 / $141.82
| Professional | | $59.72 | $92.47 | $141.82 |