- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.37 / $268.08 / $310.97
| Professional | | $201.37 | $268.08 | $310.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.86 / $460.74 / $951.26
| Professional | | $390.86 | $460.74 | $951.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.08 / $400.63 / $583.00
| Professional | | $257.08 | $400.63 | $583.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.14 / $393.72 / $583.00
| Professional | | $307.14 | $393.72 | $583.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.77 / $366.17 / $1,064.48
| Professional | | $322.77 | $366.17 | $1,064.48 |