- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.28 / $115.93 / $505.00
| Professional | | $80.28 | $115.93 | $505.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.84 / $198.84 / $234.39
| Professional | | $198.84 | $198.84 | $234.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.74 / $154.24 / $435.08
| Professional | | $106.74 | $154.24 | $435.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.33 / $194.88 / $435.08
| Professional | | $138.33 | $194.88 | $435.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.31 / $176.31 / $534.02
| Professional | | $159.31 | $176.31 | $534.02 |