- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.05 / $140.76 / $233.89
| Professional | | $116.05 | $140.76 | $233.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.80 / $204.75 / $304.47
| Professional | | $135.80 | $204.75 | $304.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.07 / $213.44 / $391.29
| Professional | | $131.07 | $213.44 | $391.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,760.08 / $1,812.88 / $1,812.88
| Professional | | $1,760.08 | $1,812.88 | $1,812.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.97 / $191.08 / $345.75
| Professional | | $124.97 | $191.08 | $345.75 |