- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.64 / $135.87 / $246.38
| Professional | | $109.64 | $135.87 | $246.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.06 / $156.66 / $261.11
| Professional | | $110.06 | $156.66 | $261.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.65 / $158.69 / $271.81
| Professional | | $115.65 | $158.69 | $271.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.71 / $903.71 / $1,006.58
| Professional | | $903.71 | $903.71 | $1,006.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.62 / $140.75 / $258.82
| Professional | | $102.62 | $140.75 | $258.82 |