- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.63 / $160.63 / $266.98
| Professional | | $160.63 | $160.63 | $266.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.84 / $173.45 / $660.00
| Professional | | $128.84 | $173.45 | $660.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.44 / $256.92 / $549.69
| Professional | | $154.44 | $256.92 | $549.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.04 / $551.05 / $551.05
| Professional | | $258.04 | $551.05 | $551.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.33 / $533.66 / $642.50
| Professional | | $222.33 | $533.66 | $642.50 |