- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.22 / $35.06 / $67.22
| Professional | | $17.22 | $35.06 | $67.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.00 / $74.00 / $74.00
| Professional | | $74.00 | $74.00 | $74.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.73 / $46.94 / $80.19
| Professional | | $22.73 | $46.94 | $80.19 |
- 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
- $29.41 / $45.83 / $108.23
| Professional | | $29.41 | $45.83 | $108.23 |