- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.26 / $167.17 / $437.17
| Professional | | $120.26 | $167.17 | $437.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.37 / $191.58 / $251.80
| Professional | | $160.37 | $191.58 | $251.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.35 / $308.29 / $727.05
| Professional | | $168.35 | $308.29 | $727.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.22 / $376.49 / $723.48
| Professional | | $163.22 | $376.49 | $723.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.26 / $167.17 / $437.17
| Professional | | $120.26 | $167.17 | $437.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.99 / $480.10 / $763.51
| Professional | | $253.99 | $480.10 | $763.51 |