- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.55 / $235.55 / $330.56
| Professional | | $162.55 | $235.55 | $330.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.47 / $263.88 / $391.32
| Professional | | $169.47 | $263.88 | $391.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.80 / $155.75 / $220.25
| Professional | | $26.80 | $155.75 | $220.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.81 / $305.04 / $413.77
| Professional | | $210.81 | $305.04 | $413.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.15 / $235.80 / $471.61
| Professional | | $216.15 | $235.80 | $471.61 |