- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $83.95 / $363.44
| Professional | | $52.47 | $83.95 | $363.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.92 / $265.92 / $265.92
| Professional | | $265.92 | $265.92 | $265.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $84.12 / $265.92
| Professional | | $48.98 | $84.12 | $265.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.23 / $102.18 / $265.92
| Professional | | $63.23 | $102.18 | $265.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.30 / $97.06 / $326.39
| Professional | | $85.30 | $97.06 | $326.39 |