- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.53 / $133.71 / $193.18
| Professional | | $102.53 | $133.71 | $193.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.80 / $128.00 / $193.97
| Professional | | $108.80 | $128.00 | $193.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.51 / $202.63 / $304.63
| Professional | | $123.51 | $202.63 | $304.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.01 / $196.21 / $332.48
| Professional | | $122.01 | $196.21 | $332.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.25 / $181.94 / $212.39
| Professional | | $117.25 | $181.94 | $212.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.60 / $220.64 / $330.60
| Professional | | $157.60 | $220.64 | $330.60 |