- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.43 / $134.41 / $305.00
| Professional | | $122.43 | $134.41 | $305.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.43 / $196.67 / $418.01
| Professional | | $185.43 | $196.67 | $418.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.29 / $186.72 / $306.68
| Professional | | $134.29 | $186.72 | $306.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.76 / $186.72 / $306.68
| Professional | | $135.76 | $186.72 | $306.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.07 / $194.94 / $301.44
| Professional | | $143.07 | $194.94 | $301.44 |