- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.08 / $40.13 / $97.78
| Professional | | $28.08 | $40.13 | $97.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.33 / $168.33 / $201.68
| Professional | | $168.33 | $168.33 | $201.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.25 / $29.37 / $36.68
| Professional | | $24.25 | $29.37 | $36.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.13 / $77.58 / $91.27
| Professional | | $61.13 | $77.58 | $91.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.40 / $48.46 / $72.14
| Professional | | $30.40 | $48.46 | $72.14 |