- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.50 / $136.93 / $174.79
| Professional | | $109.50 | $136.93 | $174.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.43 / $158.44 / $194.75
| Professional | | $146.43 | $158.44 | $194.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.00 / $157.65 / $432.39
| Professional | | $105.00 | $157.65 | $432.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.37 / $145.69 / $381.74
| Professional | | $118.37 | $145.69 | $381.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.00 / $170.04 / $377.25
| Professional | | $110.00 | $170.04 | $377.25 |