- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.77 / $278.06 / $375.97
| Professional | | $106.77 | $278.06 | $375.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $175.28
| Professional | | $175.28 | $175.28 | $175.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.46 / $408.00 / $500.73
| Professional | | $389.46 | $408.00 | $500.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.55 / $240.55 / $240.55
| Professional | | $240.55 | $240.55 | $240.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.49 / $196.92 / $222.55
| Professional | | $171.49 | $196.92 | $222.55 |