- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.27 / $180.00 / $903.87
| Professional | | $146.27 | $180.00 | $903.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.25 / $211.75 / $298.57
| Professional | | $204.25 | $211.75 | $298.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.69 / $599.87 / $722.26
| Professional | | $103.69 | $599.87 | $722.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.74 / $164.50 / $303.51
| Professional | | $128.74 | $164.50 | $303.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.07 / $204.38 / $304.54
| Professional | | $144.07 | $204.38 | $304.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.08 / $181.89 / $202.09
| Professional | | $158.08 | $181.89 | $202.09 |