- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.51 / $126.12 / $652.03
| Professional | | $116.51 | $126.12 | $652.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.55 / $161.55 / $437.94
| Professional | | $161.55 | $161.55 | $437.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.73 / $170.00 / $505.38
| Professional | | $114.73 | $170.00 | $505.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.69 / $173.60 / $437.94
| Professional | | $130.69 | $173.60 | $437.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.18 / $167.83 / $511.79
| Professional | | $113.18 | $167.83 | $511.79 |