- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.49 / $217.28 / $806.21
| Professional | | $151.49 | $217.28 | $806.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.97 / $239.97 / $793.36
| Professional | | $239.97 | $239.97 | $793.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.00 / $304.42 / $793.36
| Professional | | $173.00 | $304.42 | $793.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.95 / $313.80 / $793.36
| Professional | | $220.95 | $313.80 | $793.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.61 / $306.31 / $973.76
| Professional | | $251.61 | $306.31 | $973.76 |