- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.89 / $76.28 / $143.22
| Professional | | $39.89 | $76.28 | $143.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.00 / $103.00 / $103.00
| Professional | | $103.00 | $103.00 | $103.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.01 / $85.72 / $162.68
| Professional | | $40.01 | $85.72 | $162.68 |
- 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
- $59.03 / $89.97 / $106.97
| Professional | | $59.03 | $89.97 | $106.97 |