- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.68 / $131.68 / $167.76
| Professional | | $131.68 | $131.68 | $167.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.22 / $137.91 / $1,845.00
| Professional | | $118.22 | $137.91 | $1,845.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.39 / $172.60 / $411.68
| Professional | | $123.39 | $172.60 | $411.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.06 / $329.40 / $329.40
| Professional | | $151.06 | $329.40 | $329.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.81 / $304.72 / $428.05
| Professional | | $132.81 | $304.72 | $428.05 |