- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.84 / $223.76 / $829.77
| Professional | | $168.84 | $223.76 | $829.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.02 / $189.02 / $654.48
| Professional | | $189.02 | $189.02 | $654.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.86 / $266.23 / $654.48
| Professional | | $173.86 | $266.23 | $654.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.34 / $309.45 / $654.48
| Professional | | $255.34 | $309.45 | $654.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.60 / $260.36 / $803.30
| Professional | | $246.60 | $260.36 | $803.30 |