- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $131.83 / $181.97
| Professional | | $107.15 | $131.83 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $147.91 / $251.19
| Professional | | $66.07 | $147.91 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $147.91 / $263.03
| Professional | | $107.15 | $147.91 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,000.00 / $1,000.00
| Professional | | $870.96 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $134.90 / $239.88
| Professional | | $100.00 | $134.90 | $239.88 |