- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $67.61 / $87.10
| Professional | | $52.48 | $67.61 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $81.28 / $100.00
| Professional | | $81.28 | $81.28 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.38 / $77.62 / $123.03
| Professional | | $17.38 | $77.62 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $89.13 / $123.03
| Professional | | $21.38 | $89.13 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $60.26 / $109.65
| Professional | | $32.36 | $60.26 | $109.65 |