- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.67 / $17.50 / $89.03
| Professional | | $13.67 | $17.50 | $89.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.12 / $13.12 / $660.00
| Professional | | $13.12 | $13.12 | $660.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.47 / $79.28 / $241.73
| Professional | | $15.47 | $79.28 | $241.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.89 / $190.36 / $190.36
| Professional | | $33.89 | $190.36 | $190.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.54 / $109.09 / $230.48
| Professional | | $63.54 | $109.09 | $230.48 |