- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.87 / $143.69 / $252.23
| Professional | | $106.87 | $143.69 | $252.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.10 / $111.10 / $111.10
| Professional | | $111.10 | $111.10 | $111.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.30 / $114.00 / $153.13
| Professional | | $101.30 | $114.00 | $153.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.39 / $143.68 / $260.58
| Professional | | $98.39 | $143.68 | $260.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.25 / $172.35 / $1,082.32
| Professional | | $117.25 | $172.35 | $1,082.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.50 / $141.71 / $276.24
| Professional | | $112.50 | $141.71 | $276.24 |