- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.50 / $222.49 / $290.75
| Professional | | $162.50 | $222.49 | $290.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.90 / $296.24 / $423.28
| Professional | | $221.90 | $296.24 | $423.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.71 / $343.19 / $552.00
| Professional | | $217.71 | $343.19 | $552.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.32 / $346.38 / $577.39
| Professional | | $247.32 | $346.38 | $577.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.50 / $222.49 / $319.36
| Professional | | $162.50 | $222.49 | $319.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.06 / $384.50 / $608.70
| Professional | | $267.06 | $384.50 | $608.70 |