- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.54 / $38.90 / $131.83
| Professional | | $27.54 | $38.90 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $43.65
| Professional | | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $47.86 / $61.66
| Professional | | $32.36 | $47.86 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.90 / $42.66 / $1,000.00
| Professional | | $30.90 | $42.66 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.90 / $42.66 / $53.70
| Professional | | $30.90 | $42.66 | $53.70 |