- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.91 / $208.40 / $330.45
| Professional | | $156.91 | $208.40 | $330.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.92 / $221.08 / $313.48
| Professional | | $187.92 | $221.08 | $313.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.78 / $323.26 / $509.47
| Professional | | $201.78 | $323.26 | $509.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.63 / $319.45 / $554.89
| Professional | | $203.63 | $319.45 | $554.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.29 / $208.40 / $330.45
| Professional | | $169.29 | $208.40 | $330.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.71 / $340.42 / $527.92
| Professional | | $224.71 | $340.42 | $527.92 |