- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.31 / $128.77 / $235.62
| Professional | | $96.31 | $128.77 | $235.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.95 / $157.44 / $193.75
| Professional | | $125.95 | $157.44 | $193.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.33 / $148.40 / $245.01
| Professional | | $101.33 | $148.40 | $245.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.06 / $162.15 / $1,060.00
| Professional | | $120.06 | $162.15 | $1,060.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.30 / $145.08 / $290.88
| Professional | | $117.30 | $145.08 | $290.88 |