- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $346.74 / $588.84
| Professional | | $190.55 | $346.74 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $389.05 / $724.44
| Professional | | $194.98 | $389.05 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $478.63 / $977.24
| Professional | | $239.88 | $478.63 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $489.78 / $1,000.00
| Professional | | $239.88 | $489.78 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $524.81 / $1,071.52
| Professional | | $257.04 | $524.81 | $1,071.52 |