- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.17 / $132.30 / $643.00
| Professional | | $106.17 | $132.30 | $643.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.20 / $228.20 / $228.20
| Professional | | $228.20 | $228.20 | $228.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.67 / $160.97 / $238.05
| Professional | | $122.67 | $160.97 | $238.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.19 / $177.36 / $255.23
| Professional | | $125.19 | $177.36 | $255.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.96 / $158.34 / $222.46
| Professional | | $141.96 | $158.34 | $222.46 |