- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.62 / $240.74 / $1,063.00
| Professional | | $78.62 | $240.74 | $1,063.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.65 / $305.56 / $907.49
| Professional | | $250.65 | $305.56 | $907.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.83 / $216.72 / $907.49
| Professional | | $106.83 | $216.72 | $907.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.15 / $318.13 / $907.49
| Professional | | $113.15 | $318.13 | $907.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.51 / $324.10 / $1,113.83
| Professional | | $222.51 | $324.10 | $1,113.83 |