- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.24 / $199.00 / $199.00
| Professional | | $149.24 | $199.00 | $199.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.27 / $169.27 / $211.59
| Professional | | $169.27 | $169.27 | $211.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.84 / $167.84 / $217.43
| Professional | | $167.84 | $167.84 | $217.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.35 / $210.39 / $419.10
| Professional | | $190.35 | $210.39 | $419.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.69 / $152.69 / $152.69
| Facility | | $152.69 | $152.69 | $152.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.18 / $229.05 / $516.99
| Professional | | $149.18 | $229.05 | $516.99 |