- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.39 / $153.33 / $234.13
| Professional | | $114.39 | $153.33 | $234.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.67 / $165.06 / $265.68
| Professional | | $120.67 | $165.06 | $265.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.51 / $184.26 / $284.77
| Professional | | $124.51 | $184.26 | $284.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,654.97 / $2,654.97 / $2,654.97
| Professional | | $2,654.97 | $2,654.97 | $2,654.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.31 / $180.57 / $301.86
| Professional | | $124.31 | $180.57 | $301.86 |