- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $173.78 / $512.86
| Professional | | $109.65 | $173.78 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $165.96 / $537.03
| Professional | | $165.96 | $165.96 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $169.82 / $239.88
| Professional | | $117.49 | $169.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $199.53 / $251.19
| Professional | | $151.36 | $199.53 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $199.53 / $354.81
| Professional | | $144.54 | $199.53 | $354.81 |