- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.00 / $125.35 / $303.33
| Professional | | $121.00 | $125.35 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.76 / $158.76 / $417.12
| Professional | | $158.76 | $158.76 | $417.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.47 / $177.89 / $431.94
| Professional | | $111.47 | $177.89 | $431.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.00 / $293.16 / $346.19
| Professional | | $139.00 | $293.16 | $346.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.32 / $150.27 / $409.08
| Professional | | $105.32 | $150.27 | $409.08 |