- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.18 / $127.90 / $155.00
| Professional | | $105.18 | $127.90 | $155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.03 / $177.05 / $202.51
| Professional | | $143.03 | $177.05 | $202.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.83 / $157.07 / $231.08
| Professional | | $101.83 | $157.07 | $231.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.83 / $157.07 / $231.08
| Professional | | $101.83 | $157.07 | $231.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.79 / $162.65 / $295.08
| Professional | | $112.79 | $162.65 | $295.08 |