- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.88 / $226.01 / $226.01
| Professional | | $195.88 | $226.01 | $226.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.08 / $277.24 / $316.05
| Professional | | $241.08 | $277.24 | $316.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.72 / $159.72 / $159.72
| Professional | | $159.72 | $159.72 | $159.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.35 / $346.55 / $452.03
| Professional | | $301.35 | $346.55 | $452.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.57 / $135.61 / $271.22
| Professional | | $126.57 | $135.61 | $271.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.68 / $239.57 / $239.57
| Professional | | $150.68 | $239.57 | $239.57 |