- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.28 / $94.19 / $143.00
| Professional | | $88.28 | $94.19 | $143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.92 / $108.92 / $108.92
| Professional | | $108.92 | $108.92 | $108.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.02 / $83.59 / $153.12
| Professional | | $78.02 | $83.59 | $153.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.30 / $141.77 / $202.02
| Professional | | $103.30 | $141.77 | $202.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.40 / $130.18 / $239.43
| Professional | | $100.40 | $130.18 | $239.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.04 / $101.04 / $101.04
| Professional | | $101.04 | $101.04 | $101.04 |