- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.64 / $199.64 / $206.54
| Professional | | $199.64 | $199.64 | $206.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.44 / $262.95 / $388.51
| Professional | | $214.44 | $262.95 | $388.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.47 / $299.45 / $440.92
| Professional | | $236.47 | $299.45 | $440.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.51 / $290.44 / $445.55
| Professional | | $225.51 | $290.44 | $445.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.64 / $199.64 / $206.54
| Professional | | $199.64 | $199.64 | $206.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.01 / $288.54 / $405.35
| Professional | | $212.01 | $288.54 | $405.35 |