- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.51 / $236.51 / $236.51
| Professional | | $236.51 | $236.51 | $236.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.00 / $237.08 / $1,643.00
| Professional | | $98.00 | $237.08 | $1,643.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.66 / $260.05 / $522.04
| Professional | | $198.66 | $260.05 | $522.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.21 / $442.30 / $442.30
| Professional | | $197.21 | $442.30 | $442.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.58 / $445.56 / $526.98
| Professional | | $180.58 | $445.56 | $526.98 |