- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.04 / $152.35 / $152.35
| Professional | | $152.04 | $152.35 | $152.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.75 / $170.75 / $625.71
| Professional | | $170.75 | $170.75 | $625.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.42 / $207.22 / $625.71
| Professional | | $198.42 | $207.22 | $625.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.42 / $207.22 / $625.71
| Professional | | $198.42 | $207.22 | $625.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.79 / $213.36 / $665.60
| Professional | | $146.79 | $213.36 | $665.60 |