- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.97 / $184.69 / $612.00
| Professional | | $105.97 | $184.69 | $612.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.11 / $266.52 / $470.54
| Professional | | $226.11 | $266.52 | $470.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.58 / $202.31 / $470.54
| Professional | | $150.58 | $202.31 | $470.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.74 / $202.31 / $373.89
| Professional | | $160.74 | $202.31 | $373.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.25 / $227.40 / $338.73
| Professional | | $142.25 | $227.40 | $338.73 |