- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.46 / $139.75 / $242.01
| Professional | | $98.46 | $139.75 | $242.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.38 / $178.77 / $281.07
| Professional | | $117.38 | $178.77 | $281.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.26 / $181.54 / $297.02
| Professional | | $124.26 | $181.54 | $297.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.00 / $1,135.68 / $1,330.05
| Professional | | $816.00 | $1,135.68 | $1,330.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.72 / $173.38 / $327.11
| Professional | | $137.72 | $173.38 | $327.11 |