- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.35 / $87.45 / $120.59
| Professional | | $46.35 | $87.45 | $120.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.51 / $147.93 / $429.44
| Professional | | $120.51 | $147.93 | $429.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.32 / $123.89 / $340.89
| Professional | | $48.32 | $123.89 | $340.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.08 / $128.93 / $340.89
| Professional | | $65.08 | $128.93 | $340.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.87 / $165.30 / $480.53
| Professional | | $102.87 | $165.30 | $480.53 |