- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.32 / $209.09 / $618.91
| Professional | | $111.32 | $209.09 | $618.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.24 / $254.96 / $398.00
| Professional | | $148.24 | $254.96 | $398.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.65 / $140.51 / $194.07
| Professional | | $25.65 | $140.51 | $194.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.61 / $267.39 / $428.66
| Professional | | $166.61 | $267.39 | $428.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.20 / $275.10 / $446.41
| Professional | | $192.20 | $275.10 | $446.41 |