- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $123.03 / $239.88
| Professional | | $77.62 | $123.03 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $165.96 / $234.42
| Professional | | $107.15 | $165.96 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $165.96 / $263.03
| Professional | | $131.83 | $165.96 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $173.78 / $363.08
| Professional | | $134.90 | $173.78 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $144.54 / $245.47
| Professional | | $91.20 | $144.54 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $43.65 / $43.65 / $43.65
| Professional | 52 | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $144.54 / $269.15
| Professional | | $100.00 | $144.54 | $269.15 |