- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.00 / $53.30 / $53.30
| Professional | | $35.00 | $53.30 | $53.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.02 / $132.27 / $145.03
| Professional | | $110.02 | $132.27 | $145.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.42 / $111.71 / $192.51
| Professional | | $41.42 | $111.71 | $192.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.46 / $53.75 / $293.57
| Professional | | $28.46 | $53.75 | $293.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.06 / $55.92 / $85.22
| Professional | | $30.06 | $55.92 | $85.22 |