- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $112.20 / $177.83
| Professional | | $64.57 | $112.20 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $100.00 / $138.04
| Professional | | $48.98 | $100.00 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $158.49 / $208.93
| Professional | | $158.49 | $158.49 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $70.79 / $112.20
| Professional | | $57.54 | $70.79 | $112.20 |