- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $112.20 / $125.89
| Professional | | $64.57 | $112.20 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $114.82 / $158.49
| Professional | | $53.70 | $114.82 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $158.49 / $208.93
| Professional | | $158.49 | $158.49 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $70.79 / $112.20
| Professional | | $57.54 | $70.79 | $112.20 |