- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.63 / $114.63 / $163.87
| Professional | | $114.63 | $114.63 | $163.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.07 / $131.91 / $1,410.00
| Professional | | $125.07 | $131.91 | $1,410.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.78 / $204.92 / $431.89
| Professional | | $114.78 | $204.92 | $431.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.39 / $365.07 / $365.07
| Professional | | $255.39 | $365.07 | $365.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.24 / $349.51 / $450.10
| Professional | | $115.24 | $349.51 | $450.10 |