- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.47 / $47.85 / $56.62
| Professional | | $42.47 | $47.85 | $56.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.70 / $58.70 / $58.70
| Professional | | $58.70 | $58.70 | $58.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.81 / $117.81 / $117.81
| Professional | | $117.81 | $117.81 | $117.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.47 / $48.13 / $59.74
| Professional | | $42.47 | $48.13 | $59.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.40 / $54.12 / $119.23
| Professional | | $45.40 | $54.12 | $119.23 |