- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.02 / $50.41 / $99.09
| Professional | | $30.02 | $50.41 | $99.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.00 / $102.00 / $102.00
| Professional | | $102.00 | $102.00 | $102.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.04 / $61.71 / $102.26
| Professional | | $40.04 | $61.71 | $102.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.27 / $56.28 / $109.19
| Professional | | $45.27 | $56.28 | $109.19 |