- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.75 / $134.99 / $371.11
| Professional | | $110.75 | $134.99 | $371.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.76 / $294.50 / $368.12
| Professional | | $286.76 | $294.50 | $368.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.58 / $259.30 / $2,654.97
| Professional | | $155.58 | $259.30 | $2,654.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.00 / $286.76 / $349.49
| Professional | | $228.00 | $286.76 | $349.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.61 / $222.22 / $254.88
| Professional | | $162.61 | $222.22 | $254.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.58 / $259.30 / $358.04
| Professional | | $155.58 | $259.30 | $358.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.80 / $285.60 / $297.10
| Professional | | $242.80 | $285.60 | $297.10 |