- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.38 / $346.20 / $453.62
| Professional | | $146.38 | $346.20 | $453.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.87 / $366.87 / $366.87
| Professional | | $366.87 | $366.87 | $366.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.23 / $213.23 / $414.38
| Professional | | $213.23 | $213.23 | $414.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $518.04 / $906.57
| Professional | | $100.00 | $518.04 | $906.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.91 / $221.62 / $317.95
| Professional | | $204.91 | $221.62 | $317.95 |