- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.61 / $48.48 / $180.00
| Professional | | $37.61 | $48.48 | $180.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.36 / $68.36 / $138.26
| Professional | | $68.36 | $68.36 | $138.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.85 / $51.32 / $138.26
| Professional | | $36.85 | $51.32 | $138.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.31 / $62.78 / $138.26
| Professional | | $47.31 | $62.78 | $138.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.11 / $54.38 / $169.70
| Professional | | $51.11 | $54.38 | $169.70 |