- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.74 / $175.55 / $221.26
| Professional | | $95.74 | $175.55 | $221.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.60 / $104.60 / $104.60
| Professional | | $104.60 | $104.60 | $104.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.27 / $167.54 / $217.92
| Professional | | $98.27 | $167.54 | $217.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.83 / $152.83 / $152.83
| Professional | | $152.83 | $152.83 | $152.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.59 / $108.72 / $134.03
| Professional | | $93.59 | $108.72 | $134.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.57 / $290.57 / $290.57
| Professional | | $290.57 | $290.57 | $290.57 |