- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.53 / $82.17 / $365.83
| Professional | | $47.53 | $82.17 | $365.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.36 / $120.66 / $235.63
| Professional | | $102.36 | $120.66 | $235.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.33 / $97.11 / $235.63
| Professional | | $75.33 | $97.11 | $235.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.33 / $97.11 / $186.94
| Professional | | $75.33 | $97.11 | $186.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.12 / $109.23 / $164.35
| Professional | | $69.12 | $109.23 | $164.35 |