- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.66 / $235.58 / $409.13
| Professional | | $133.66 | $235.58 | $409.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.69 / $254.44 / $431.85
| Professional | | $149.69 | $254.44 | $431.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.07 / $263.95 / $450.24
| Professional | | $158.07 | $263.95 | $450.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.00 / $1,905.76 / $2,231.63
| Professional | | $1,054.00 | $1,905.76 | $2,231.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.63 / $295.99 / $517.87
| Professional | | $208.63 | $295.99 | $517.87 |