- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.10 / $265.10 / $464.53
| Professional | | $265.10 | $265.10 | $464.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.43 / $352.53 / $557.40
| Professional | | $307.43 | $352.53 | $557.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.95 / $397.53 / $569.53
| Professional | | $330.95 | $397.53 | $569.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.50 / $380.58 / $583.84
| Professional | | $295.50 | $380.58 | $583.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.10 / $265.10 / $464.53
| Professional | | $265.10 | $265.10 | $464.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.80 / $393.17 / $526.97
| Professional | | $327.80 | $393.17 | $526.97 |