- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $316.23 / $562.34
| Professional | | $190.55 | $316.23 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $288.40 / $446.68
| Professional | | $218.78 | $288.40 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $363.08 / $630.96
| Professional | | $229.09 | $363.08 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $354.81 / $758.58
| Professional | | $186.21 | $354.81 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $338.84 / $380.19
| Professional | | $186.21 | $338.84 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $371.54 / $660.69
| Professional | | $218.78 | $371.54 | $660.69 |