- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.79 / $190.76 / $413.87
| Professional | | $150.79 | $190.76 | $413.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.16 / $301.58 / $301.58
| Professional | | $274.16 | $301.58 | $301.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $175.28
| Professional | | $175.28 | $175.28 | $175.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.00 / $408.00 / $408.00
| Professional | | $408.00 | $408.00 | $408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.63 / $182.18 / $246.72
| Professional | | $142.63 | $182.18 | $246.72 |