- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.22 / $271.02 / $376.13
| Professional | | $122.22 | $271.02 | $376.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.58 / $301.58 / $301.58
| Professional | | $301.58 | $301.58 | $301.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $340.62
| Professional | | $175.28 | $175.28 | $340.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $365.17 / $639.04
| Professional | | $100.00 | $365.17 | $639.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.44 / $182.18 / $343.24
| Professional | | $168.44 | $182.18 | $343.24 |