- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.00 / $275.77 / $275.77
| Professional | | $224.00 | $275.77 | $275.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.96 / $233.17 / $350.32
| Professional | | $190.96 | $233.17 | $350.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.19 / $275.77 / $385.18
| Professional | | $232.19 | $275.77 | $385.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.96 / $222.59 / $346.35
| Professional | | $199.96 | $222.59 | $346.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.00 / $275.77 / $275.77
| Professional | | $224.00 | $275.77 | $275.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.27 / $266.38 / $346.15
| Professional | | $188.27 | $266.38 | $346.15 |