- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.26 / $124.30 / $271.73
| Professional | | $107.26 | $124.30 | $271.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.68 / $126.32 / $660.00
| Professional | | $118.68 | $126.32 | $660.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.81 / $181.36 / $321.23
| Professional | | $109.81 | $181.36 | $321.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.53 / $281.63 / $281.63
| Professional | | $244.53 | $281.63 | $281.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.26 / $241.70 / $333.00
| Professional | | $91.26 | $241.70 | $333.00 |