- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.97 / $176.18 / $379.62
| Professional | | $159.97 | $176.18 | $379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.71 / $219.43 / $258.14
| Professional | | $180.71 | $219.43 | $258.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.16 / $232.00 / $260.86
| Professional | | $168.16 | $232.00 | $260.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.76 / $217.45 / $1,103.57
| Professional | | $175.76 | $217.45 | $1,103.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.97 / $212.21 / $266.10
| Professional | | $166.97 | $212.21 | $266.10 |