- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.40 / $209.26 / $355.26
| Professional | | $150.40 | $209.26 | $355.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.09 / $222.46 / $324.42
| Professional | | $189.09 | $222.46 | $324.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.54 / $337.60 / $588.87
| Professional | | $203.54 | $337.60 | $588.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.87 / $377.99 / $606.83
| Professional | | $211.87 | $377.99 | $606.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.40 / $209.26 / $355.26
| Professional | | $150.40 | $209.26 | $355.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.58 / $390.86 / $603.62
| Professional | | $241.58 | $390.86 | $603.62 |