- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.89 / $41.69 / $52.48
| Professional | | $20.89 | $41.69 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.12 / $25.12 / $97.72
| Professional | | $25.12 | $25.12 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $104.71 / $104.71
| Professional | | $100.00 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $138.04
| Professional | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.42 / $32.36 / $107.15
| Professional | | $20.42 | $32.36 | $107.15 |