- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.30 / $304.26 / $441.03
| Professional | | $177.30 | $304.26 | $441.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.47 / $359.31 / $606.36
| Professional | | $209.47 | $359.31 | $606.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.52 / $364.62 / $600.95
| Professional | | $223.52 | $364.62 | $600.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.48 / $2,423.92 / $2,853.83
| Professional | | $1,450.48 | $2,423.92 | $2,853.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.33 / $381.92 / $698.45
| Professional | | $298.33 | $381.92 | $698.45 |