- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.85 / $194.84 / $272.60
| Professional | | $166.85 | $194.84 | $272.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.95 / $259.27 / $497.45
| Professional | | $219.95 | $259.27 | $497.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.57 / $261.61 / $402.70
| Professional | | $185.57 | $261.61 | $402.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.40 / $301.89 / $402.70
| Professional | | $201.40 | $301.89 | $402.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.11 / $292.29 / $600.23
| Professional | | $203.11 | $292.29 | $600.23 |