- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.32 / $145.46 / $481.00
| Professional | | $122.32 | $145.46 | $481.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.03 / $249.48 / $280.42
| Professional | | $198.03 | $249.48 | $280.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.41 / $203.10 / $326.49
| Professional | | $143.41 | $203.10 | $326.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.41 / $203.91 / $326.49
| Professional | | $143.41 | $203.91 | $326.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.80 / $206.06 / $320.22
| Professional | | $153.80 | $206.06 | $320.22 |