- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.07 / $28.08 / $28.08
| Professional | | $26.07 | $28.08 | $28.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.00 / $31.02 / $115.20
| Professional | | $24.00 | $31.02 | $115.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.58 / $83.54 / $116.06
| Professional | | $20.58 | $83.54 | $116.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.51 / $39.64 / $39.64
| Professional | | $36.51 | $39.64 | $39.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.72 / $39.64 / $87.09
| Professional | | $21.72 | $39.64 | $87.09 |