- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.84 / $105.43 / $500.00
| Professional | | $69.84 | $105.43 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.39 / $120.91 / $161.96
| Professional | | $94.39 | $120.91 | $161.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.63 / $143.30 / $166.97
| Professional | | $117.63 | $143.30 | $166.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.83 / $72.83 / $103.08
| Professional | | $72.83 | $72.83 | $103.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.53 / $151.91 / $175.26
| Professional | | $96.53 | $151.91 | $175.26 |