- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $218.78 / $478.63
| Professional | | $173.78 | $218.78 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $295.12 / $426.58
| Professional | | $194.98 | $295.12 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $269.15 / $446.68
| Professional | | $204.17 | $269.15 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $302.00 / $562.34
| Professional | | $251.19 | $302.00 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $257.04 / $602.56
| Professional | | $177.83 | $257.04 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $251.19 / $436.52
| Professional | | $162.18 | $251.19 | $436.52 |