- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.48 / $115.08 / $140.56
| Professional | | $73.48 | $115.08 | $140.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.29 / $58.29 / $58.29
| Professional | | $58.29 | $58.29 | $58.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.54 / $142.87 / $142.87
| Professional | | $33.54 | $142.87 | $142.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.58 / $71.27 / $83.86
| Professional | | $60.58 | $71.27 | $83.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.87 / $142.87 / $142.87
| Professional | | $142.87 | $142.87 | $142.87 |