- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.68 / $160.07 / $160.07
| Professional | | $147.68 | $160.07 | $160.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.15 / $271.52 / $916.92
| Professional | | $204.15 | $271.52 | $916.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.52 / $425.36 / $822.73
| Professional | | $145.52 | $425.36 | $822.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.81 / $390.99 / $390.99
| Professional | | $172.81 | $390.99 | $390.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.94 / $207.54 / $584.88
| Professional | | $175.94 | $207.54 | $584.88 |