- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.54 / $114.70 / $274.00
| Professional | | $104.54 | $114.70 | $274.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.31 / $169.51 / $356.91
| Professional | | $158.31 | $169.51 | $356.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.46 / $163.13 / $267.39
| Professional | | $117.46 | $163.13 | $267.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.51 / $163.13 / $267.39
| Professional | | $118.51 | $163.13 | $267.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.71 / $167.94 / $264.24
| Professional | | $124.71 | $167.94 | $264.24 |