- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.91 / $158.69 / $277.14
| Professional | | $131.91 | $158.69 | $277.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.25 / $247.00 / $372.69
| Professional | | $75.25 | $247.00 | $372.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.96 / $280.87 / $475.23
| Professional | | $170.96 | $280.87 | $475.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,529.71 / $1,575.61 / $1,575.61
| Professional | | $1,529.71 | $1,575.61 | $1,575.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.31 / $229.58 / $513.79
| Professional | | $181.31 | $229.58 | $513.79 |