- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.75 / $130.60 / $172.25
| Professional | | $118.75 | $130.60 | $172.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.64 / $185.05 / $259.98
| Professional | | $113.64 | $185.05 | $259.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.05 / $253.61 / $328.01
| Professional | | $191.05 | $253.61 | $328.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.91 / $248.64 / $352.64
| Professional | | $198.91 | $248.64 | $352.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.25 / $255.68 / $332.99
| Professional | | $161.25 | $255.68 | $332.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.91 / $248.64 / $311.60
| Professional | | $198.91 | $248.64 | $311.60 |