- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $144.54 / $234.42
| Professional | | $112.20 | $144.54 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $120.23 / $147.91
| Professional | | $100.00 | $120.23 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $151.36 / $251.19
| Professional | | $120.23 | $151.36 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $162.18 / $295.12
| Professional | | $123.03 | $162.18 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,000.00 / $1,000.00
| Professional | | $891.25 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $147.91 / $229.09
| Professional | | $117.49 | $147.91 | $229.09 |