- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.59 / $174.24 / $623.00
| Professional | | $113.59 | $174.24 | $623.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.15 / $203.15 / $239.47
| Professional | | $203.15 | $203.15 | $239.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.30 / $183.64 / $551.08
| Professional | | $140.30 | $183.64 | $551.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.28 / $226.68 / $551.08
| Professional | | $165.28 | $226.68 | $551.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.32 / $205.60 / $676.40
| Professional | | $176.32 | $205.60 | $676.40 |