- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.25 / $125.13 / $316.86
| Professional | | $90.25 | $125.13 | $316.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.66 / $132.88 / $202.92
| Professional | | $105.66 | $132.88 | $202.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.80 / $167.06 / $279.45
| Professional | | $116.80 | $167.06 | $279.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.12 / $212.44 / $1,060.00
| Professional | | $140.12 | $212.44 | $1,060.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.72 / $174.34 / $291.19
| Professional | | $129.72 | $174.34 | $291.19 |