- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.83 / $356.06 / $698.22
| Professional | | $243.83 | $356.06 | $698.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.06 / $380.74 / $510.75
| Professional | | $278.06 | $380.74 | $510.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.45 / $424.91 / $720.02
| Professional | | $285.45 | $424.91 | $720.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.80 / $445.65 / $465.55
| Professional | | $378.80 | $445.65 | $465.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.00 / $414.75 / $710.94
| Professional | | $316.00 | $414.75 | $710.94 |