- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $208.93 / $512.86
| Professional | | $165.96 | $208.93 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $263.03 / $389.05
| Professional | | $169.82 | $263.03 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $269.15 / $416.87
| Professional | | $208.93 | $269.15 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $275.42 / $524.81
| Professional | | $213.80 | $275.42 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $257.04 / $602.56
| Professional | | $181.97 | $257.04 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $245.47 / $426.58
| Professional | | $169.82 | $245.47 | $426.58 |