- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.61 / $155.50 / $510.49
| Professional | | $112.61 | $155.50 | $510.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.86 / $135.88 / $155.32
| Professional | | $125.86 | $135.88 | $155.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.92 / $180.00 / $370.33
| Professional | | $118.92 | $180.00 | $370.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.82 / $203.25 / $329.66
| Professional | | $152.82 | $203.25 | $329.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.58 / $157.90 / $285.08
| Professional | | $113.58 | $157.90 | $285.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.65 / $175.74 / $217.32
| Professional | | $113.65 | $175.74 | $217.32 |