- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $147.91 / $281.84
| Professional | | $120.23 | $147.91 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $190.55 / $309.03
| Professional | | $138.04 | $190.55 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $181.97 / $288.40
| Professional | | $125.89 | $181.97 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Professional | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $177.83 / $281.84
| Professional | | $123.03 | $177.83 | $281.84 |