- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $107.15 / $223.87
| Professional | | $91.20 | $107.15 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $151.36 / $223.87
| Professional | | $87.10 | $151.36 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $147.91 / $223.87
| Professional | | $125.89 | $147.91 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $131.83 / $204.17
| Professional | | $107.15 | $131.83 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $114.82 / $363.08
| Professional | | $97.72 | $114.82 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $147.91 / $204.17
| Professional | | $107.15 | $147.91 | $204.17 |