- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.97 / $166.97 / $166.97
| Professional | | $166.97 | $166.97 | $166.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.72 / $179.19 / $328.02
| Professional | | $150.72 | $179.19 | $328.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.38 / $270.98 / $319.93
| Professional | | $176.38 | $270.98 | $319.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.06 / $197.92 / $303.61
| Professional | | $171.06 | $197.92 | $303.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.97 / $166.97 / $166.97
| Professional | | $166.97 | $166.97 | $166.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.93 / $258.77 / $303.61
| Professional | | $154.93 | $258.77 | $303.61 |