- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.71 / $144.71 / $144.71
| Professional | | $144.71 | $144.71 | $144.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.99 / $175.05 / $17,986.00
| Professional | | $128.99 | $175.05 | $17,986.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.40 / $153.33 / $289.85
| Professional | | $116.40 | $153.33 | $289.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.85 / $262.85 / $262.85
| Professional | | $262.85 | $262.85 | $262.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.50 / $189.05 / $354.38
| Professional | | $106.50 | $189.05 | $354.38 |