- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.15 / $237.51 / $334.81
| Professional | | $74.15 | $237.51 | $334.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.74 / $240.18 / $505.30
| Professional | | $97.74 | $240.18 | $505.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.20 / $290.75 / $526.50
| Professional | | $113.20 | $290.75 | $526.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.70 / $2,179.28 / $2,554.28
| Professional | | $1,074.70 | $2,179.28 | $2,554.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.82 / $405.66 / $667.16
| Professional | | $273.82 | $405.66 | $667.16 |