- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.47 / $143.47 / $147.91
| Professional | | $143.47 | $143.47 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.70 / $151.53 / $154.75
| Professional | | $112.70 | $151.53 | $154.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.31 / $154.41 / $201.61
| Professional | | $115.31 | $154.41 | $201.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.93 / $149.86 / $1,700.00
| Professional | | $103.93 | $149.86 | $1,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.57 / $131.41 / $194.49
| Professional | | $95.57 | $131.41 | $194.49 |