- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.75 / $62.11 / $136.06
| Professional | | $42.75 | $62.11 | $136.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.00 / $106.00 / $106.00
| Professional | | $106.00 | $106.00 | $106.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.27 / $85.48 / $123.34
| Professional | | $53.27 | $85.48 | $123.34 |
- 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
- $59.72 / $77.62 / $164.88
| Professional | | $59.72 | $77.62 | $164.88 |