- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.11 / $78.40 / $113.17
| Professional | | $54.11 | $78.40 | $113.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.52 / $130.52 / $151.65
| Professional | | $130.52 | $130.52 | $151.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.55 / $111.12 / $167.94
| Professional | | $69.55 | $111.12 | $167.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.10 / $150.10 / $174.40
| Professional | | $150.10 | $150.10 | $174.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.54 / $88.33 / $152.35
| Professional | | $50.54 | $88.33 | $152.35 |