- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.92 / $68.15 / $104.73
| Professional | | $42.92 | $68.15 | $104.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.41 / $68.41 / $68.41
| Professional | | $68.41 | $68.41 | $68.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.42 / $74.56 / $103.94
| Professional | | $56.42 | $74.56 | $103.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.68 / $74.73 / $113.06
| Professional | | $48.68 | $74.73 | $113.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.63 / $72.31 / $120.84
| Professional | | $55.63 | $72.31 | $120.84 |