- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.07 / $161.07 / $312.95
| Professional | | $161.07 | $161.07 | $312.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.22 / $156.72 / $2,116.00
| Professional | | $115.22 | $156.72 | $2,116.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.69 / $266.69 / $580.83
| Professional | | $142.69 | $266.69 | $580.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.91 / $590.78 / $590.78
| Professional | | $263.91 | $590.78 | $590.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.71 / $323.81 / $703.90
| Professional | | $213.71 | $323.81 | $703.90 |