- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.14 / $106.06 / $220.26
| Professional | | $65.14 | $106.06 | $220.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.52 / $142.87 / $142.87
| Professional | | $139.52 | $142.87 | $142.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.29 / $58.29 / $58.29
| Professional | | $58.29 | $58.29 | $58.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.50 / $116.50 / $116.50
| Professional | | $116.50 | $116.50 | $116.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.88 / $71.27 / $100.63
| Professional | | $57.88 | $71.27 | $100.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.53 / $130.76 / $3,375.00
| Professional | | $104.53 | $130.76 | $3,375.00 |