- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.78 / $222.99 / $339.54
| Professional | | $109.78 | $222.99 | $339.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.48 / $212.86 / $252.55
| Professional | | $109.48 | $212.86 | $252.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.91 / $187.80 / $377.20
| Professional | | $139.91 | $187.80 | $377.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.38 / $253.28 / $253.28
| Professional | | $206.38 | $253.28 | $253.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.59 / $224.37 / $420.40
| Professional | | $139.59 | $224.37 | $420.40 |