- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $199.53 / $269.15
| Professional | | $81.28 | $199.53 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $199.53
| Professional | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $288.40
| Professional | | $114.82 | $114.82 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $426.58 / $575.44
| Professional | | $323.59 | $426.58 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $316.23 / $323.59
| Professional | | $239.88 | $316.23 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $120.23 / $239.88
| Professional | | $109.65 | $120.23 | $239.88 |