- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.98 / $221.56 / $302.95
| Professional | | $112.98 | $221.56 | $302.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.28 / $167.16 / $302.54
| Professional | | $95.28 | $167.16 | $302.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.18 / $213.03 / $393.95
| Professional | | $110.18 | $213.03 | $393.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.77 / $1,494.45 / $1,574.78
| Professional | | $818.77 | $1,494.45 | $1,574.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.36 / $268.20 / $505.31
| Professional | | $211.36 | $268.20 | $505.31 |