- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.95 / $114.07 / $495.56
| Professional | | $86.95 | $114.07 | $495.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.35 / $323.35 / $501.22
| Professional | | $323.35 | $323.35 | $501.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.74 / $164.14 / $501.22
| Professional | | $117.74 | $164.14 | $501.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.74 / $199.52 / $501.22
| Professional | | $127.74 | $199.52 | $501.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.50 / $179.54 / $615.20
| Professional | | $147.50 | $179.54 | $615.20 |