- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.40 / $207.78 / $755.07
| Professional | | $136.40 | $207.78 | $755.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.43 / $290.43 / $290.43
| Professional | | $290.43 | $290.43 | $290.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.42 / $321.82 / $960.58
| Professional | | $198.42 | $321.82 | $960.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.79 / $327.87 / $960.58
| Professional | | $213.79 | $327.87 | $960.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.95 / $351.86 / $1,179.00
| Professional | | $262.95 | $351.86 | $1,179.00 |