- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.28 / $231.11 / $370.38
| Professional | | $145.28 | $231.11 | $370.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.78 / $283.95 / $459.43
| Professional | | $175.78 | $283.95 | $459.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.29 / $283.32 / $461.88
| Professional | | $182.29 | $283.32 | $461.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.80 / $1,859.28 / $2,174.55
| Professional | | $1,188.80 | $1,859.28 | $2,174.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.73 / $288.12 / $530.66
| Professional | | $224.73 | $288.12 | $530.66 |