- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.17 / $180.70 / $646.00
| Professional | | $106.17 | $180.70 | $646.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.27 / $193.18 / $236.20
| Professional | | $132.27 | $193.18 | $236.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.03 / $207.29 / $496.46
| Professional | | $153.03 | $207.29 | $496.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.46 / $168.56 / $178.01
| Professional | | $117.46 | $168.56 | $178.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.36 / $190.89 / $326.42
| Professional | | $127.36 | $190.89 | $326.42 |