- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $89.13 / $114.82
| Professional | | $63.10 | $89.13 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $75.86 / $75.86
| Professional | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $213.80
| Professional | | $109.65 | $109.65 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $93.33 / $251.19
| Professional | | $69.18 | $93.33 | $251.19 |