- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.58 / $119.62 / $119.62
| Professional | | $66.58 | $119.62 | $119.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.81 / $132.81 / $136.79
| Professional | | $132.81 | $132.81 | $136.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.07 / $120.82 / $364.49
| Professional | | $104.07 | $120.82 | $364.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.89 / $277.73 / $277.73
| Professional | | $121.89 | $277.73 | $277.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.81 / $100.98 / $299.14
| Professional | | $69.81 | $100.98 | $299.14 |