- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $154.88 / $263.03
| Professional | | $109.65 | $154.88 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $346.74 / $416.87
| Professional | | $295.12 | $346.74 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $147.91
| Professional | | $120.23 | $120.23 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Professional | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $120.23 / $263.03
| Professional | | $109.65 | $120.23 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $158.49 / $758.58
| Professional | | $144.54 | $158.49 | $758.58 |