- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.18 / $130.07 / $239.47
| Professional | | $105.18 | $130.07 | $239.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.51 / $109.51 / $110.25
| Professional | | $109.51 | $109.51 | $110.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.60 / $357.12 / $394.30
| Professional | | $297.60 | $357.12 | $394.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.18 / $276.00 / $555.00
| Professional | | $168.18 | $276.00 | $555.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.76 / $276.00 / $603.90
| Professional | | $140.76 | $276.00 | $603.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.47 / $352.88 / $444.11
| Professional | | $314.47 | $352.88 | $444.11 |