- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $288.40 / $309.03
| Professional | | $239.88 | $288.40 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $204.17 / $426.58
| Professional | | $125.89 | $204.17 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Professional | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $57.54 / $57.54
| Professional | | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $295.12 / $371.54
| Professional | | $239.88 | $295.12 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $57.54 / $57.54
| Professional | | $57.54 | $57.54 | $57.54 |