- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.12 / $227.74 / $260.17
| Professional | | $164.12 | $227.74 | $260.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.12 / $358.49 / $808.57
| Professional | | $304.12 | $358.49 | $808.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.12 / $339.58 / $491.38
| Professional | | $216.12 | $339.58 | $491.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.62 / $322.38 / $491.38
| Professional | | $248.62 | $322.38 | $491.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.25 / $308.63 / $897.21
| Professional | | $247.25 | $308.63 | $897.21 |