- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.08 / $159.90 / $205.33
| Professional | | $112.08 | $159.90 | $205.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.62 / $158.66 / $278.35
| Professional | | $114.62 | $158.66 | $278.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.58 / $179.26 / $280.26
| Professional | | $128.58 | $179.26 | $280.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,418.00 / $1,418.00 / $1,418.00
| Professional | | $1,418.00 | $1,418.00 | $1,418.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.07 / $208.27 / $322.43
| Professional | | $134.07 | $208.27 | $322.43 |