- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.53 / $120.80 / $211.20
| Professional | | $37.53 | $120.80 | $211.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.68 / $101.86 / $247.96
| Professional | | $35.68 | $101.86 | $247.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.76 / $110.00 / $256.99
| Professional | | $37.76 | $110.00 | $256.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.71 / $65.40 / $252.65
| Professional | | $0.71 | $65.40 | $252.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.48 / $39.15 / $252.65
| Professional | | $0.48 | $39.15 | $252.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.13 / $164.65 / $280.35
| Professional | | $109.13 | $164.65 | $280.35 |