- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.56 / $199.09 / $274.43
| Professional | | $148.56 | $199.09 | $274.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.48 / $271.33 / $827.64
| Professional | | $223.48 | $271.33 | $827.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.38 / $219.84 / $561.20
| Professional | | $160.38 | $219.84 | $561.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.10 / $283.45 / $561.20
| Professional | | $200.10 | $283.45 | $561.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.00 / $249.30 / $786.83
| Professional | | $203.00 | $249.30 | $786.83 |