- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.44 / $171.08 / $582.05
| Professional | | $118.44 | $171.08 | $582.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.32 / $206.32 / $206.32
| Professional | | $206.32 | $206.32 | $206.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.22 / $219.65 / $540.34
| Professional | | $117.22 | $219.65 | $540.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.63 / $233.91 / $540.34
| Professional | | $154.63 | $233.91 | $540.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.81 / $223.74 / $663.21
| Professional | | $187.81 | $223.74 | $663.21 |