- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.29 / $226.14 / $801.00
| Professional | | $108.29 | $226.14 | $801.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.85 / $302.77 / $807.10
| Professional | | $256.85 | $302.77 | $807.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.37 / $271.20 / $807.10
| Professional | | $153.37 | $271.20 | $807.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.47 / $294.81 / $807.10
| Professional | | $160.47 | $294.81 | $807.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.83 / $300.37 / $990.63
| Professional | | $228.83 | $300.37 | $990.63 |