- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.79 / $162.21 / $261.47
| Professional | | $115.79 | $162.21 | $261.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.69 / $249.16 / $318.52
| Professional | | $157.69 | $249.16 | $318.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.69 / $268.79 / $467.65
| Professional | | $162.69 | $268.79 | $467.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.12 / $258.45 / $402.15
| Professional | | $166.12 | $258.45 | $402.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.79 / $162.21 / $261.47
| Professional | | $115.79 | $162.21 | $261.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.64 / $301.08 / $426.89
| Professional | | $202.64 | $301.08 | $426.89 |