- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.86 / $123.73 / $167.56
| Professional | | $113.86 | $123.73 | $167.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.44 / $179.20 / $213.40
| Professional | | $135.44 | $179.20 | $213.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.89 / $172.72 / $218.39
| Professional | | $119.89 | $172.72 | $218.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.24 / $156.50 / $886.02
| Professional | | $119.24 | $156.50 | $886.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.24 / $148.81 / $200.41
| Professional | | $119.24 | $148.81 | $200.41 |