- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.57 / $162.06 / $252.09
| Professional | | $109.57 | $162.06 | $252.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.52 / $169.25 / $293.86
| Professional | | $112.52 | $169.25 | $293.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.88 / $200.97 / $323.37
| Professional | | $127.88 | $200.97 | $323.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.00 / $1,404.16 / $1,656.60
| Professional | | $949.00 | $1,404.16 | $1,656.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.33 / $220.63 / $352.80
| Professional | | $157.33 | $220.63 | $352.80 |