- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.67 / $140.40 / $150.00
| Professional | | $113.67 | $140.40 | $150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.14 / $153.00 / $251.40
| Professional | | $121.14 | $153.00 | $251.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.82 / $194.62 / $319.60
| Professional | | $125.82 | $194.62 | $319.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.67 / $224.79 / $1,156.83
| Professional | | $126.67 | $224.79 | $1,156.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.50 / $160.13 / $377.04
| Professional | | $122.50 | $160.13 | $377.04 |