- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.70 / $158.84 / $548.00
| Professional | | $96.70 | $158.84 | $548.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.66 / $177.66 / $209.43
| Professional | | $177.66 | $177.66 | $209.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.66 / $186.92 / $549.79
| Professional | | $130.66 | $186.92 | $549.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.55 / $227.96 / $549.79
| Professional | | $158.55 | $227.96 | $549.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.26 / $207.30 / $674.82
| Professional | | $195.26 | $207.30 | $674.82 |