- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.58 / $207.28 / $344.85
| Professional | | $135.58 | $207.28 | $344.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.19 / $253.71 / $412.38
| Professional | | $160.19 | $253.71 | $412.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.88 / $303.33 / $610.74
| Professional | | $166.88 | $303.33 | $610.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.70 / $299.20 / $518.24
| Professional | | $165.70 | $299.20 | $518.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.58 / $207.28 / $344.85
| Professional | | $135.58 | $207.28 | $344.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.67 / $371.04 / $555.82
| Professional | | $264.67 | $371.04 | $555.82 |