- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.51 / $148.83 / $261.83
| Professional | | $110.51 | $148.83 | $261.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.37 / $161.24 / $262.45
| Professional | | $116.37 | $161.24 | $262.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.00 / $185.25 / $289.39
| Professional | | $123.00 | $185.25 | $289.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.60 / $1,232.93 / $1,392.15
| Professional | | $815.60 | $1,232.93 | $1,392.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.63 / $198.80 / $311.30
| Professional | | $140.63 | $198.80 | $311.30 |