- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.19 / $82.31 / $342.00
| Professional | | $68.19 | $82.31 | $342.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.47 / $162.04 / $256.27
| Professional | | $137.47 | $162.04 | $256.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.70 / $99.40 / $293.49
| Professional | | $68.70 | $99.40 | $293.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.73 / $101.43 / $256.27
| Professional | | $76.73 | $101.43 | $256.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.47 / $103.40 / $300.60
| Professional | | $66.47 | $103.40 | $300.60 |