- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.43 / $85.12 / $142.94
| Professional | | $57.43 | $85.12 | $142.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.48 / $410.48 / $410.48
| Professional | | $410.48 | $410.48 | $410.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.69 / $126.77 / $252.46
| Professional | | $67.69 | $126.77 | $252.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.13 / $144.31 / $252.46
| Professional | | $73.13 | $144.31 | $252.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.18 / $181.23 / $460.96
| Professional | | $150.18 | $181.23 | $460.96 |