- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.08 / $218.97 / $528.46
| Professional | | $215.08 | $218.97 | $528.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.54 / $289.77 / $853.74
| Professional | | $243.54 | $289.77 | $853.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.89 / $291.12 / $853.74
| Professional | | $218.89 | $291.12 | $853.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.03 / $336.85 / $853.74
| Professional | | $224.03 | $336.85 | $853.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.74 / $306.49 / $890.98
| Professional | | $206.74 | $306.49 | $890.98 |