- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.33 / $141.33 / $155.72
| Professional | | $128.33 | $141.33 | $155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.00 / $143.37 / $2,116.00
| Professional | | $143.00 | $143.37 | $2,116.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.66 / $211.19 / $418.37
| Professional | | $128.66 | $211.19 | $418.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.41 / $353.51 / $353.51
| Professional | | $291.41 | $353.51 | $353.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.54 / $207.24 / $428.00
| Professional | | $118.54 | $207.24 | $428.00 |