- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.44 / $203.30 / $351.53
| Professional | | $144.44 | $203.30 | $351.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.75 / $260.77 / $398.40
| Professional | | $175.75 | $260.77 | $398.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.18 / $265.27 / $417.30
| Professional | | $182.18 | $265.27 | $417.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.20 / $1,622.08 / $1,900.28
| Professional | | $1,159.20 | $1,622.08 | $1,900.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.71 / $241.76 / $443.69
| Professional | | $195.71 | $241.76 | $443.69 |