- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.28 / $41.16 / $155.51
| Professional | | $32.28 | $41.16 | $155.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $75.00 / $75.00
| Professional | | $75.00 | $75.00 | $75.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.26 / $50.50 / $75.84
| Professional | | $35.26 | $50.50 | $75.84 |
- 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
- $29.66 / $36.40 / $77.38
| Professional | | $29.66 | $36.40 | $77.38 |