- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.35 / $148.76 / $239.16
| Professional | | $113.35 | $148.76 | $239.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.91 / $191.90 / $292.69
| Professional | | $137.91 | $191.90 | $292.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.09 / $198.16 / $312.02
| Professional | | $142.09 | $198.16 | $312.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.72 / $1,120.40 / $1,275.98
| Professional | | $936.72 | $1,120.40 | $1,275.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.30 / $168.22 / $316.35
| Professional | | $136.30 | $168.22 | $316.35 |