- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.63 / $183.95 / $275.52
| Professional | | $106.63 | $183.95 | $275.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.15 / $294.72 / $675.00
| Professional | | $131.15 | $294.72 | $675.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.06 / $374.50 / $459.80
| Professional | | $250.06 | $374.50 | $459.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.43 / $234.02 / $371.88
| Professional | | $104.43 | $234.02 | $371.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.68 / $244.69 / $535.55
| Professional | | $182.68 | $244.69 | $535.55 |