- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.28 / $202.21 / $740.00
| Professional | | $166.28 | $202.21 | $740.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.48 / $262.25 / $727.18
| Professional | | $222.48 | $262.25 | $727.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.99 / $252.63 / $857.57
| Professional | | $180.99 | $252.63 | $857.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.39 / $257.70 / $727.18
| Professional | | $192.39 | $257.70 | $727.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.79 / $241.24 / $758.75
| Professional | | $167.79 | $241.24 | $758.75 |