- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.52 / $153.16 / $178.69
| Professional | | $119.52 | $153.16 | $178.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.16 / $151.88 / $250.51
| Professional | | $114.16 | $151.88 | $250.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.13 / $175.63 / $271.41
| Professional | | $127.13 | $175.63 | $271.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.88 / $1,156.83 / $1,195.00
| Professional | | $997.88 | $1,156.83 | $1,195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.22 / $184.79 / $275.22
| Professional | | $119.22 | $184.79 | $275.22 |