- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.75 / $190.58 / $767.00
| Professional | | $155.75 | $190.58 | $767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.64 / $278.94 / $558.30
| Professional | | $236.64 | $278.94 | $558.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.81 / $268.87 / $558.30
| Professional | | $176.81 | $268.87 | $558.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.70 / $266.30 / $558.30
| Professional | | $229.70 | $266.30 | $558.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.45 / $225.18 / $654.60
| Professional | | $210.45 | $225.18 | $654.60 |