- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $162.18 / $426.58
| Professional | | $114.82 | $162.18 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $131.83 / $257.04
| Professional | | $104.71 | $131.83 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $229.09 / $380.19
| Professional | | $125.89 | $229.09 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $234.42 / $1,778.28
| Professional | | $131.83 | $234.42 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $186.21 / $316.23
| Professional | | $128.82 | $186.21 | $316.23 |