- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.26 / $248.48 / $452.22
| Professional | | $144.26 | $248.48 | $452.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.00 / $352.98 / $575.48
| Professional | | $167.00 | $352.98 | $575.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.27 / $284.16 / $622.60
| Professional | | $191.27 | $284.16 | $622.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.13 / $414.51 / $532.79
| Professional | | $294.13 | $414.51 | $532.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.67 / $385.38 / $965.66
| Professional | | $220.67 | $385.38 | $965.66 |