- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.62 / $240.62 / $548.57
| Professional | | $240.62 | $240.62 | $548.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.50 / $220.11 / $220.11
| Professional | | $202.50 | $220.11 | $220.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.18 / $298.41 / $427.52
| Professional | | $241.18 | $298.41 | $427.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.44 / $285.20 / $437.51
| Professional | | $221.44 | $285.20 | $437.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.62 / $240.62 / $548.57
| Professional | | $240.62 | $240.62 | $548.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.25 / $276.75 / $408.61
| Professional | | $193.25 | $276.75 | $408.61 |