- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.31 / $267.83 / $267.83
| Professional | | $142.31 | $267.83 | $267.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.94 / $300.92 / $455.27
| Professional | | $242.94 | $300.92 | $455.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.77 / $331.95 / $497.53
| Professional | | $255.77 | $331.95 | $497.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.51 / $341.95 / $524.57
| Professional | | $265.51 | $341.95 | $524.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.31 / $267.83 / $267.83
| Professional | | $142.31 | $267.83 | $267.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.70 / $314.04 / $459.06
| Professional | | $277.70 | $314.04 | $459.06 |