- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.06 / $142.28 / $176.00
| Professional | | $101.06 | $142.28 | $176.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.80 / $262.63 / $524.25
| Professional | | $222.80 | $262.63 | $524.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.74 / $213.32 / $324.39
| Professional | | $144.74 | $213.32 | $324.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.72 / $199.71 / $324.39
| Professional | | $149.72 | $199.71 | $324.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.13 / $203.74 / $592.29
| Professional | | $183.13 | $203.74 | $592.29 |