- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.55 / $325.66 / $342.88
| Professional | | $210.55 | $325.66 | $342.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.45 / $298.64 / $410.43
| Professional | | $184.45 | $298.64 | $410.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.13 / $330.79 / $518.71
| Professional | | $190.13 | $330.79 | $518.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.66 / $325.60 / $1,491.84
| Professional | | $265.66 | $325.60 | $1,491.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.41 / $322.39 / $407.00
| Professional | | $259.41 | $322.39 | $407.00 |