- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.15 / $68.58 / $81.53
| Professional | | $61.15 | $68.58 | $81.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.67 / $84.67 / $84.67
| Professional | | $84.67 | $84.67 | $84.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.44 / $167.44 / $167.44
| Professional | | $167.44 | $167.44 | $167.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.15 / $69.30 / $86.62
| Professional | | $61.15 | $69.30 | $86.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.28 / $78.63 / $170.87
| Professional | | $65.28 | $78.63 | $170.87 |