- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.47 / $212.18 / $815.00
| Professional | | $136.47 | $212.18 | $815.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.83 / $253.83 / $313.87
| Professional | | $253.83 | $253.83 | $313.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.91 / $221.56 / $939.46
| Professional | | $163.91 | $221.56 | $939.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.12 / $213.50 / $939.46
| Professional | | $149.12 | $213.50 | $939.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.79 / $289.20 / $1,153.08
| Professional | | $182.79 | $289.20 | $1,153.08 |