- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.38 / $342.88 / $619.74
| Professional | | $212.38 | $342.88 | $619.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.20 / $320.20 / $447.55
| Professional | | $320.20 | $320.20 | $447.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.37 / $341.79 / $535.00
| Professional | | $224.37 | $341.79 | $535.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.16 / $400.14 / $1,491.84
| Professional | | $303.16 | $400.14 | $1,491.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.85 / $375.05 / $512.79
| Professional | | $302.85 | $375.05 | $512.79 |