- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.68 / $193.43 / $227.57
| Professional | | $170.68 | $193.43 | $227.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.19 / $235.19 / $235.19
| Professional | | $235.19 | $235.19 | $235.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.71 / $473.71 / $473.71
| Professional | | $473.71 | $473.71 | $473.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.68 / $194.00 / $235.87
| Professional | | $170.68 | $194.00 | $235.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.18 / $210.69 / $483.40
| Professional | | $184.18 | $210.69 | $483.40 |