- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.55 / $125.55 / $173.60
| Professional | | $125.55 | $125.55 | $173.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.58 / $167.92 / $660.00
| Professional | | $111.58 | $167.92 | $660.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.71 / $193.27 / $463.44
| Professional | | $139.71 | $193.27 | $463.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.25 / $468.80 / $468.80
| Professional | | $209.25 | $468.80 | $468.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.06 / $323.82 / $544.11
| Professional | | $156.06 | $323.82 | $544.11 |