- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.70 / $71.77 / $127.05
| Professional | | $46.70 | $71.77 | $127.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.70 / $95.57 / $287.12
| Professional | | $78.70 | $95.57 | $287.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.50 / $76.01 / $201.35
| Professional | | $48.50 | $76.01 | $201.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.31 / $103.00 / $201.35
| Professional | | $65.31 | $103.00 | $201.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.55 / $98.07 / $285.10
| Professional | | $73.55 | $98.07 | $285.10 |