- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.97 / $164.64 / $686.00
| Professional | | $115.97 | $164.64 | $686.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.58 / $194.91 / $284.62
| Professional | | $132.58 | $194.91 | $284.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.82 / $122.33 / $150.06
| Professional | | $95.82 | $122.33 | $150.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.09 / $231.69 / $359.59
| Professional | | $167.09 | $231.69 | $359.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.30 / $161.13 / $249.38
| Professional | | $132.30 | $161.13 | $249.38 |