- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.65 / $81.79 / $112.92
| Professional | | $58.65 | $81.79 | $112.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.77 / $122.32 / $351.86
| Professional | | $103.77 | $122.32 | $351.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.67 / $130.74 / $212.89
| Professional | | $89.67 | $130.74 | $212.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.32 / $132.72 / $212.89
| Professional | | $94.32 | $132.72 | $212.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.33 / $133.71 / $388.72
| Professional | | $113.33 | $133.71 | $388.72 |