- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $194.98 / $676.08
| Professional | | $109.65 | $194.98 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $691.83
| Professional | | $234.42 | $234.42 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $239.88 / $691.83
| Professional | | $141.25 | $239.88 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $239.88 / $457.09
| Professional | | $190.55 | $239.88 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $194.98 / $416.87
| Professional | | $123.03 | $194.98 | $416.87 |