- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.91 / $237.55 / $356.22
| Professional | | $122.91 | $237.55 | $356.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.22 / $258.27 / $479.13
| Professional | | $136.22 | $258.27 | $479.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.62 / $270.67 / $457.33
| Professional | | $143.62 | $270.67 | $457.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,855.00 / $1,942.64 / $2,273.48
| Professional | | $1,855.00 | $1,942.64 | $2,273.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.08 / $342.62 / $565.40
| Professional | | $245.08 | $342.62 | $565.40 |