- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.91 / $126.91 / $174.33
| Professional | | $126.91 | $126.91 | $174.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.32 / $129.60 / $660.00
| Professional | | $116.32 | $129.60 | $660.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.06 / $156.97 / $427.79
| Professional | | $113.06 | $156.97 | $427.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.33 / $340.44 / $340.44
| Professional | | $155.33 | $340.44 | $340.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $288.60 / $442.40
| Professional | | $128.82 | $288.60 | $442.40 |