- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $218.78 / $323.59
| Professional | | $109.65 | $218.78 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Professional | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $295.12
| Professional | | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $173.78 / $371.54
| Professional | | $93.33 | $173.78 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $199.53 / $309.03
| Professional | | $109.65 | $199.53 | $309.03 |