- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.92 / $182.34 / $262.93
| Professional | | $68.92 | $182.34 | $262.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.94 / $114.94 / $114.94
| Professional | | $114.94 | $114.94 | $114.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.43 / $263.41 / $323.27
| Professional | | $251.43 | $263.41 | $323.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.31 / $155.31 / $155.31
| Professional | | $155.31 | $155.31 | $155.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.45 / $135.40 / $150.43
| Professional | | $112.45 | $135.40 | $150.43 |