- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.61 / $229.75 / $380.59
| Professional | | $173.61 | $229.75 | $380.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.98 / $252.00 / $405.63
| Professional | | $188.98 | $252.00 | $405.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.63 / $300.45 / $534.33
| Professional | | $195.63 | $300.45 | $534.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.12 / $372.85 / $2,148.96
| Professional | | $241.12 | $372.85 | $2,148.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.45 / $319.83 / $532.58
| Professional | | $228.45 | $319.83 | $532.58 |