- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.47 / $191.47 / $314.57
| Professional | | $191.47 | $191.47 | $314.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.19 / $254.34 / $254.34
| Professional | | $216.19 | $254.34 | $254.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.27 / $293.75 / $395.64
| Professional | | $190.27 | $293.75 | $395.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.25 / $257.20 / $1,418.24
| Professional | | $200.25 | $257.20 | $1,418.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.52 / $242.70 / $379.41
| Professional | | $194.52 | $242.70 | $379.41 |