- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.26 / $165.90 / $649.64
| Professional | | $125.26 | $165.90 | $649.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.68 / $237.68 / $746.13
| Professional | | $237.68 | $237.68 | $746.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.07 / $277.88 / $746.13
| Professional | | $159.07 | $277.88 | $746.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.92 / $277.88 / $746.13
| Professional | | $180.92 | $277.88 | $746.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.17 / $286.58 / $915.80
| Professional | | $209.17 | $286.58 | $915.80 |