- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.70 / $164.71 / $293.83
| Professional | | $87.70 | $164.71 | $293.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.13 / $128.97 / $209.05
| Professional | | $106.13 | $128.97 | $209.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.38 / $229.14 / $512.04
| Professional | | $129.38 | $229.14 | $512.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.49 / $326.05 / $523.44
| Professional | | $131.49 | $326.05 | $523.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.70 / $164.71 / $293.83
| Professional | | $87.70 | $164.71 | $293.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.55 / $308.86 / $617.57
| Professional | | $226.55 | $308.86 | $617.57 |