- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.15 / $119.54 / $224.88
| Professional | | $77.15 | $119.54 | $224.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.00 / $190.00 / $190.00
| Professional | | $190.00 | $190.00 | $190.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.20 / $136.72 / $239.91
| Professional | | $81.20 | $136.72 | $239.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.98 / $139.44 / $261.89
| Professional | | $107.98 | $139.44 | $261.89 |