- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.81 / $145.06 / $228.58
| Professional | | $135.81 | $145.06 | $228.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.13 / $285.70 / $335.01
| Professional | | $254.13 | $285.70 | $335.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.78 / $330.02 / $426.17
| Professional | | $203.78 | $330.02 | $426.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.06 / $246.19 / $1,624.00
| Professional | | $136.06 | $246.19 | $1,624.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.06 / $224.50 / $293.25
| Professional | | $136.06 | $224.50 | $293.25 |