- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.91 / $154.91 / $154.91
| Professional | | $154.91 | $154.91 | $154.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.88 / $159.83 / $1,845.00
| Professional | | $145.88 | $159.83 | $1,845.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.53 / $177.61 / $331.95
| Professional | | $131.53 | $177.61 | $331.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.38 / $297.27 / $297.27
| Professional | | $135.38 | $297.27 | $297.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.16 / $189.31 / $354.20
| Professional | | $121.16 | $189.31 | $354.20 |