- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.86 / $198.50 / $343.83
| Professional | | $91.86 | $198.50 | $343.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.00 / $322.00 / $322.00
| Professional | | $322.00 | $322.00 | $322.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.00 / $185.87 / $271.87
| Professional | | $123.00 | $185.87 | $271.87 |
- 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
- $125.97 / $164.27 / $357.08
| Professional | | $125.97 | $164.27 | $357.08 |