- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.74 / $145.22 / $145.22
| Professional | | $142.74 | $145.22 | $145.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.76 / $81.79 / $89.27
| Professional | | $68.76 | $81.79 | $89.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.83 / $172.00 / $208.49
| Professional | | $134.83 | $172.00 | $208.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.83 / $172.73 / $2,654.97
| Professional | | $120.83 | $172.73 | $2,654.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.11 / $150.22 / $242.05
| Professional | | $114.11 | $150.22 | $242.05 |