- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $181.97 / $363.08
| Professional | | $109.65 | $181.97 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $213.80 / $213.80
| Professional | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $239.88 / $691.83
| Professional | | $144.54 | $239.88 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $245.47 / $457.09
| Professional | | $190.55 | $245.47 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $199.53 / $416.87
| Professional | | $125.89 | $199.53 | $416.87 |