- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.78 / $235.78 / $235.78
| Professional | | $235.78 | $235.78 | $235.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.70 / $305.20 / $339.00
| Professional | | $260.70 | $305.20 | $339.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.49 / $231.73 / $289.54
| Professional | | $156.49 | $231.73 | $289.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $210.47
| Professional | | $32.34 | $32.34 | $210.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.42 / $213.43 / $303.39
| Professional | | $181.42 | $213.43 | $303.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.97 / $244.26 / $342.48
| Professional | | $176.97 | $244.26 | $342.48 |